Membership Application

Directions: Please fill out this membership application with the following required information. Along with this, please provide the necessary documents and answer each question to the best of your organization's ability. Once complete, CyManII's Governance Board will review and approve those who qualify. Until then, please wait to hear from our Director of Strategic Engagement, Steve Laycock

Organizational & Contact Information

Organization Name *

DUNS Number

US Commercial and Government Entity (CAGE) Code

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Senior Leadership Representative (C-Level or Equivalent)*

Prefix (optional)

First Name

Initial (optional)

Last Name

Senior Leadership Title *

Senior Leadership Email*

Senior Leadership Phone*

Technical Representative *

Prefix (optional)

First Name

Initial (optional)

Last Name

Technical Representative Title *

Technical Representative Email *

Technical Representative Phone*

Financial Representative *

Prefix (optional)

First Name

Initial (optional)

Last Name

Financial Representative Title *

Financial Representative Email*

Financial Representative Phone*

Social Media & Website Information

Organization Website *

Facebook Handle

Instagram Handle

Twitter Handle

LinkedIn Handle

Release & Permission of Using Organization Logo or Trademark

As the undersigned authorized representative of my organization, I hereby grant permission for CyManII to publish and/or use our organization's logo or registered mark for all advertising purposes connected with the business of CyManII; This includes the cymanii.com website, marketing presentations, brochures, and any other marketing material related to CyManII and its mission.

Please select one of the following acknowledgments (this will not affect the approval status of your application)*

I grant permission for CyManII to publish our organization's logo for business purposes I decline permission for CyManII to publish our organization's logo for business purposes

Signature*

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Use your mouse or finger to draw your signature above

Date/Time*

First Name*

First Name

Last Name

Title*

Organization *

Membership Interest Information

Membership Level Request *See our Membership Level Description page for detailed information *

Managing Member $200K Strategic Member $100K Collaborative Member $25K Community Member $1K Exceptional Expectations or Requirements* (Description of expectations required should be outlined below)

U.S. Entity Self-Certification

Please note: this response must be executed by a corporate officer, typically the signing officer that will execute the CyManII Membership Agreement. Please expect additional supporting documents once the application is reviewed and approved by CyManII.

As part of our Membership Application to CyManII – The Cybersecurity Manufacturing Innovation Institute, I certify to the best of my knowledge and belief the following with respect to:

Organization Name *

This organization is incorporated (or otherwise formed) under the laws of a particular State or territory of the United States:*

Yes No

Does this organization have any foreign ownership or control?*

Yes No

Please list address of the physical place of business in the United States:*

Address Line 1

Address Line 2

City

State

ZIP Code

Signature*

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Use your mouse or finger to draw your signature above

Date/Time*

First Name*

First Name

Last Name

Non-Disclosure Agreement

Please sign and upload the Cybersecurity Manufacturing Innovation Institute Non-Disclosure Agreement (NDA).

NDA Upload*

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Organizational & Contact Information

Organizational Description Information

Social Media & Website Information

Release & Permission of Using Organization Logo or Trademark

Membership Interest Information

U.S. Entity Self-Certification

Non-Disclosure Agreement