New
Renewal Date: ______________
I N D U S T R Y M E M B E R S H I P A P P L I C AT I O N
LOS ANGELES
COMPANY INFORMATION Company Name ____________________________________________________
INDUSTRY SEGMENT & MARKET FOCUS CATEGORY ❒ Academic
❒ Non-Profit
❒ Government Agency
❒ Private Company
Address ____________________________________________________________
❒ Research Institute
❒ Public Company
City_________________________________ State _________ Zip ___________
PRIMARY TECHNOLOGY (Check One)
Phone _____________________________________________________________
❒ Aquaculture
❒ Drug Delivery
❒ Proteomics
❒ Bioinformatics
❒ Drug Development
❒ Stem Cell Research
# of Employees in California ________
❒ Biomanufacturing
❒ Epigenomics
❒ Therapeutics
# of Employees Worldwide _________
❒ Biorenewables
❒ Functional Genetics
(majority are biologics)
❒ Biosimilars
❒ Gene / Cell Therapy
❒ Therapeutics
❒ Cell Biology
❒ Genetics / Genomics
(majority are small
❒ Clinical Research
❒ Micro Arrays
molecules)
❒ Contract
❒ Microfluidics
❒ Research Tools
Manufacturer
❒ Molecular
(products support
❒ Contract Research
Diagnostics
discovery and R&D)
❒ Devices
❒ Nanotechnology
❒ Vaccines
❒ Diagnostics
❒ Platform
❒ Wearable Sensors
❒ Digital Health
Technologies
Company Website ___________________________________________________
Private ❒ Public ❒ Ticker Symbol ___________ Are you a virtual company? Yes ❒ No ❒ Do you have a lab? Yes ❒ No ❒ Do you have a cleanroom? Yes ❒ No ❒ Your fiscal year starts _____________
PRIMARY CONTACTS STAGE OF DEVELOPMENT
PRIMARY CONTACT(Responsibilities include receipt of all official correspondence, designation of company personnel to serve on Biocom committees and updates of company information)
______________________________________________________________________________ Name & Title Email Phone
ALTERNATE CONTACT
primary contact is unavailable)
(Responsibilities include receipt of all official correspondences if
______________________________________________________________________________ Name & Title Email Phone
BILLING CONTACT membership dues)
(Responsibilities include receipt of membership invoice and payment of
______________________________________________________________________________ Name & Title Email Phone
SECONDARY BILLING CONTACT (Responsibilities include receipt of membership
invoice and payment of membership dues if primary billing contact is unavailable)
______________________________________________________________________________ Name & Title Email Phone
PURCHASING CONTACT (Responsibilities include receipt of all official correspondence from Biocom Purchasing Group and Purchasing Group preferred suppliers) ______________________________________________________________________________ Name & Title Email Phone
❒ Preclinical / Research
❒ Phase II
❒ Phase IV
❒ Phase I
❒ Phase III
❒ On Market
HEALTHCARE FOCUS (Check all that apply) ❒ Allergy
❒ Food & Agriculture
❒ Pain Management
❒ Aquaculture
❒ Functional Genetics
❒ Personal Care
❒ Automimmune Disease
❒ Gastroentorology
❒ Platform Technologies
❒ Biodefense
❒ Gene / Cell Therapy
❒ Precision Medicine
❒ Bioinformatics
❒ Genetic Disorders
❒ Proteomics
❒ Biomanufacturing
❒ Genetics / Genomics
❒ Pulmonary
❒ Biorenewables
❒ Hematology
❒ Regenerative Medicine
❒ Biosimilars
❒ Immunology
❒ Renal
❒ Cardiovascular
❒ Immunotherapy
❒ Reproductive Medicine
❒ Cell Biology
❒ Infectious Diseases
❒ Research Tools
❒ Central Nervous System
❒ Inflammatory Diseases
(products support
❒ Chemicals
❒ Mental Health
discovery and R&D)
❒ Clinical Research
❒ Metabolic
❒ Respiratory
❒ Contract Manufacturer
❒ Micro Arrays
❒ Stem Cell Research
❒ Contract Research
❒ Microfluidics
❒ Therapeutics (majority
❒ Dermatology
❒ Molecular Diagnostics
are biologics)
❒ Devices
❒ Musculoskeletal
❒ Therapeutics (majority
❒ Diagnostics
❒ Nanotechnology
are small molecules)
❒ Digital Health
❒ Neurology
❒ Tissue Engineering
❒ Drug Delivery
❒ Nutraceuticals
❒ Urology
❒ Drug Development
❒ Oncology
❒ Vaccines
❒ Endocrinology
❒ Opthamology
❒ Wearable Sensors
❒ Epigenomics
❒ Orphan / Rare Diseases