Membership Application

Membership Application
Date*

MonthDayYear
Applicant Information
Company Name*
Number of years in business in US*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Please enter a valid phone number.
Email*
example@example.com
Website URL*

Membership Types
Please select which of the three membership types your company qualifies for.*

General Membership - Organizations and corporations which operate and/or sell Point of Care Media are eligible for General Membership.Affiliate Membership - Organizations who are engaged as service providers or otherwise provide support of the point of care media channel and/or those who can support healthcare providers beyond the point of care are eligible for Affiliate membership.Reciprocal Membership - Reciprocal membership is designated for other trade associations, non-profit organizations, or coalitions that have mutual interest in the point of care healthcare arena. Reciprocal Members shall not have the right to vote and shall not be considered “members” within the meaning of Section 29-401.02(24)(a) of the Act.
As a General Member, please indicate which type of General Member category you qualify for.*

General Members who have annual point of care revenue above $5MM AND who have been in business in the United States for a minimum of three years are eligible for a Board of Director seat. Eligibility excludes companies that lack Direct Provider Relationships (a direct and ongoing relationship with healthcare providers), or do not operate a proprietary Point of Care Media offering (ex. Companies who only resell inventory from another company).General Members who have annual point of care revenue below $5MM are not eligible for a Board of Director seat.
*Two General Members who have been in business in the United States for a minimum of three years and who have annual point of care revenue that falls below $5MM, may be elected to the Board upon agreement of paying an additional fee. These members elected to the board will serve on the Board for a two-year term.

Company Description
Please provide a description of your company. *
Please list who you consider to be a competitor. *

Point of Care Offering Description
Please provide a description of your Point of Care offering(s) and who your offerings target.*

Membership Request
Please explain why you are interested in becoming a member of the Point of Care Marketing Association *

Membership Requirements
To be considered for membership, company must agree to the following:

POCMA Bylaws, Ethics Policy, Antitrust Policy (Found here).

POCMA Mission Statement
Please note your agreement by checking off the following:*

abide by POCMA Bylaws, Mission Statement, Ethics Policy, Antitrust Policy, and other applicable policies adopted by the Board of Directors from time to time;must agree to maintain compliance with all applicable governmental laws and regulations; andmust not be subject to a federal or state criminal indictment, investigation, or other related action by a federal or state agency regarding the member company or its current employees involving allegations of fraud, deception, or crimes of moral turpitude that may affect the reputation of the Association.

Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to membership, I understand that false of misleading information in my application may result in membership termination.
Signature*

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Membership Application

Applicant Information

Membership Types

Company Description

Point of Care Offering Description

Membership Request

Membership Requirements

To be considered for membership, company must agree to the following:

POCMA Bylaws, Ethics Policy, Antitrust Policy (Found here).

Disclaimer and Signature