VIA Member Application - ODU Innovate

Name

First

Last

Organization Name

Main Address

Principal Point of Contact and Title

Please Indicate Your Organization Type:

Academic
Government
Industry
Affiliate (Non-profit organization providing training, information, and/or assistance to the simulation industry)

Choose Which Industry Classification and Annual Gross Revenue Option Your Organization Fits Into

Select the Annual Dues Amount Based on Selected Option Above

Cardholder Name (as shown on card). First and Last Name

Credit Card Type (Mastercard, VISA, or AMEX)

Name Organization Organization

Card Number

Expiration Date

CVV

Cardholder's Billing Address

Cardholder's City

Cardholder's State

Cardholder's ZIP Code

Total Amount To Be Billed To Credit Card