MEMBERSHIP REGISTRATION FORM Register with us by filling out the form below. SECTION 1: MEMBER DETAILSNAME IN FULL*?I.C. NO*GENDER*FEMALEMALERACE*MALAYCHINESEINDIANOthersOFFICE ADDRESSStreet Address 1Street Address 2Town / CityState / ProvincePostcode / ZipCountryTEL. NO*FAX NOE-MAILHOUSE ADDRESSStreet Address 1Street Address 2State / ProvinceTown / CityPostcode / ZipCountryH/P NO*OCCUPATION*ACADEMIC ACHIEVEMENTSTUDENTYESNOTHIS SECTION NEEDS TO BE COMPLETED IN FULL (except STUDENT)Do you work for an academic, non-profit or governmental research institution?YESNOAre you the most senior member of your institution’s technology transfer organization?*?YESNOMy place of employment is best defined as*University (includes nonprofit research organizations formed for the sole purpose of managing a university’s or college’s intellectual property)Teaching hospitalNonprofit research institutionGovernment technology transfer program and/or federal labDo you work for a for-profit entity, foundation or association?*YESNOYears of Experience (Please check one)0-23-78-1415-2021+Which of the following areas are most significant in your job? (Check all that apply)Company/spin-out developmentEconomic development identification/evaluationMarketingContract negotiationLicensing technologyResearchOther __________________SECTION 2 : PAYMENT DETAILSCORPORATE : An organization or entity directly or indirectly engaged in the field of technology transferREGISTRATION FEES : RM2,000.00, MEMBERSHIP FEE Annual : RM1000.00INDIVIDUAL : A person directly or indirectly engaged in the field of technology transferREGISTRATION FEES : RM500.00, MEMBERSHIP FEE Annual : RM250.00LIFETIME : Regular Members who fulfill the condition set by the CommitteeREGISTRATION FEES & MEMBERSHIP FEE Annual : (Korporat : RM10,000.00), (Individu: RM2,500.00)STUDENT Open to all students from higher learning institutions (not allowed to hold post, chair a meeting and vote)REGISTRATION FEES : RM100.00PAYMENT METHOD*CASHPersonal Cheque : Cheque No : __________________________Institution Cheque : : Cheque No : __________________________Note: All Cheques are to be made payable to “Innovation Technology Managers (ITMA)” Completed form to be send back to us via email to norliyana.upm@gmail.com / itma.malayssia@gmail.comITMA respects the privacy of all members and we are committed to protect all personal information kept by us pursuant to the requirements of thePersonal Data Protection Act 2010 (“the Act”). Please tick the box below if you consented for us to use and process your personal information.your content here.Acknowledgement*I / We do hereby consent to ITMA, its agents and/or permitted assigns for the collecting, recording, holding or storing my personal information within the meaning of the Act including but not limited to any information, documents, records and accounts necessary for this membership purposes.User Email*Password*Register Error occured. Please confirm your data and submit again: