Institutional Membership Form Please indicate your level of institutional membership:* Platinum Member: $15,000 Educational Grant Gold Member: $10,000 Educational Grant Silver Member: $5,000 Educational Grant Bronze Member: $2,500 Educational Grant Platinum Member - Promote your institution through a 60 second video to be shown during selected breaks - 4 free meeting registrations - Recognized as a Platinum Member during the Opening Session by the presidents of the AAS and SUS - Acknowledged as a Platinum Member on the ASC website, meeting app, in communications with registrants and throughout the course of the meeting - Receive 3 free meeting registrations - Acknowledged as a Gold Member on the ASC website, on the meeting app, in communications with registrants and throughout the course of the meeting - Receive 2 free meeting registrations - Acknowledged as a Silver Member on the ASC website, on the meeting app, in communications with registrants and throughout the course of the meeting - Receive 1 free meeting registration - Acknowledged as a Bronze Member on the ASC website, on the meeting app, in communications with registrants and throughout the course of the meeting Institution InformationInstitution Name/Title*As you want it to appear on meeting app and website Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Institution/Department Website* Pre-Meeting Logistics ContactThe Logistics Contact will serve as the liaison between the institution and ASC staff. Responsibilities include: -Payment for institutional membership -Provide Institutional LOGO -Provide Institutional VIDEO (Platinum only) -Provide Institutional profile for meeting app -Distribute discount code among those selected from your institution to receive free registration(s) and ensure they are used. Pre-Meeting Logistics Contact Name* First Last Pre-Meeting Logistics Contact Phone*Pre-Meeting Logistics Contact Email* Department Chair Name* First Last Department Chair PhoneDepartment Contact Email* Institutional RepresentativeThe Institutional representative represents your institution at the Opening Ceremonies where your institution will be recognized as an Institutional Member. They will be provided instructions as to where and when to report for the Opening Ceremonies. They will not be asked to speak or verbally accept the institutional certificate of recognitionInstitutional Representative Name First Last Institutional Representative Email Institutional Title Institutional Mobile PhoneTo be used for on-site contact, if needed.How to get your free registration(s)?Once your membership level is confirmed, your logistics contact will receive the complimentary registration discount code to distribute to the designated registrant(s) at your institution. Designated registrants will enter the discount code when registering with the ASC on-line registration system. If any designated registrant has previously registered for the meeting, the fee will be reimbursed. NOTE: Deadline to use free registration code is Monday, January 9, 2023 Institutional Logo and ProfileIf you cannot provide your logo, profile or video now, you will have the option to provide it via the link to be included in your confirmation email. Deadline: THURSDAY, DECEMBER 15, 2022Please upload your institution's logoAccepted file types: jpg, png, Max. file size: 64 MB.Institutional ProfilePlease submit a 50-75 word profile about your institution which will be highlighted on the meeting app along with your logo. Deadline: THURSDAY, DECEMBER 15, 2022Institutional Video Guidelines (Platinum Members only)Deadline: DECEMBER 15, 2022 1.Quality: Videos must be of good quality and submitted in final form 2.Acceptable formats (Windows PC compatible): MPEG, Quicktime, MP4, H.264, AVI • Framesize: No smaller than 640 x 480 • File size: Less than 1 gig 3. Runtime: 60 seconds maximum 4. Submission: Please submit your videos via Dropbox. Do not include any music, video clips or other materials/media copyrighted by any other entity other than your institution.Payment Options – I would like to*Payment deadline: Friday, January 6, 2023 Pay Now Pay later with check or a wire transfer Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged. Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)