Electronic Transactions Association
Membership Application
GENERAL INFORMATION
Company Name: (Required)
Address Line 1: (Required)
Address Line 2:
City: (Required) State/ Province: (Required)
Zip/Postal Code: (Required)
Country: (Required)
Other Country:
Main Company Phone: (Required) Main Company Fax
Web Site: (Required)

Primary Contact:
First Name: (Required)
Last Name: (Required)
Title:
Direct Phone & ext.: (Required) Direct Fax:
Email: (Required)

Voting Contact: (if different from above)
First Name:
Last Name:
Title:
Direct Phone & ext.: Direct Fax:
Email:

ETA PRIVACY POLICY (Required)
NOTE: ETA occasionally provides membership listings to other members or other interested parties. To ensure that we only provide the information you want released, please select one of the following:
My information as shown above may be distributed.
My information as shown above except for my e-mail address may be distributed.
My information as shown above should not be distributed.

MEMBERSHIP CATEGORY (Required)
Please check the category that applies to your company:
SERVICE PROVIDER
Any business entity or individual providing transactions processing services between merchants and settlement banks.
FINANCIAL INSTITUTION
Any business entity that is state or federally regulated as a financial institution.

DUES & PAYMENT (Required)
ETA dues are effective from July 1 to June 30 and billed annually. Anniversary date does not apply.

SERVICE PROVIDER
Based on gross revenue (all revenues derived from electronic transactions activity, including equipment sales, leases, etc. - minus interchange, dues and assessments.) - Check Applicable Box:
Up to $1,000,000 . . . . . . . . . . . . . . . . . . . .Annual dues $650
$1,000,000 to $5,000,000 . . . . . . . . . . . . . .Annual dues $1,250
$5,000,000 to $15,000,000 . . . . . . . . . . . . .Annual dues $1,750
$15,000,000 to $100,000,000 . . . . . . . . . . .Annual dues $2,500
Over $100,000,000 . . . . . . . . . . . . . . . . . . .Annual dues $3,000

FINANCIAL INSTITUTION
Based on total assets - Check Applicable Box:
Under $250,000,000 . . . . . . . . . . . . . . . . . .Annual dues $1,000
$250,000,000 to $10,000,000,000 . . . . . . . .Annual dues $1,500
Over $10,000,000,000 . . . . . . . . . . . . . . . . .Annual dues $2,500

ADDITIONAL REPRESENTATIVES
*Ten company representatives, as well as a primary contact and/or voting representative are included at no additional charge. You may add other individuals to your roster at $50 each (indicate qty. below), which entitles them to all member benefits.
First ten additional representatives: (provide all contact information)

Additional Company Representatives (above the first ten) Qty: x $50 each
(You will be asked to provide their contact information on the next page)