ec MMIC Sen et ues eS] eet ee eC Cron [contact information] print below [fee schedule ] company name 1 Fuimembership parent company if applicable) global sabes revenue in 1¢ of president or chief executive officer corporate website address annual membership fee in $: (see schedule on reverse) Industry sector ‘GainPace membership is based upon a calendar yoar bing cyl. An reason(s) for jolning inrested party may jn GainPass at any tive and al membership pays a rated tre hat caleuatd ona quater basi. Fue bling ejloe ‘sl begin on January fo each subsequent primary representative name title 1 Basic Membership suectaddess ——s—s—~*~*~Sséi payment information ] city, state/province postal code country (7 Please charge fee to the credit card indicated below phone fax on Ove 1D mestecara required for online access) i 1 American Express creditcard number expiration date creditcard security. billing statement Mov code (30r 4 digits) zip code (USA) name as it appears on card (print below) postal code “country ‘e-mail (required for online access) Signature financlal contact name (for invoicing, if ifferent than primary) [notice and signature ] ie We are in accor with purposes ana pins of GainPace and wish to om the GainPars Foderaon asa member We also agree fo provide 5 {miramum of 60-days notice pir to our feneval dat shuld we alack street address if different than above) man oe ay state/province ‘name (print below) postal code country ine} ae signature date ‘e-mail (required for online access) ‘application must be signed return completed application with membership fee to: Z