COG Membership Application

Membership Application Form

Please fax to: +44 (0) 1727 871 336 or mail to: Component Obsolescence Group International Ltd, Unit 3, Curo Park, St Albans, Herts, AL2 2DD, UK

---

We would like to apply for membership of the Component Obsolescence Group and accept the terms of reference agreed by the Group.

You may either print this form to mail or fax, or pay on-line via our secure server

Contact Details

Company
Address
Post Code
Contact Name
Phone
Fax
Email
Field of Activity
Notes: This data may be used by the Component Obsolescence Group through and TMT Conferences Limited to inform you of future COG events and membership benefits. Please click this box if you do not want your contact details sent to selected third parties supplying goods and services in the obsolescence management field.

Payment Details

Please check applicable box	UK Membership fee £880 + 17.5% VAT = £1034
	Non-UK Membership fee £946.00
Please send an invoice
Please find cheque attached *	(If sending by post)
Please find purchase order attached	(If sending by post)
You may either:
Print the form to fax or post (You may enter credit card details by hand if required.)
Or pay on-line by credit card using our secure server
Payment by Credit Card	Note: Subject to a 3.0% charge
Card type	Visa MasterCard Amex
Card number
Security Number	Last three digits (For Amex, last 4 digits on FRONT of card)
Expiry Date	Month  Year
Cardholders Name
Billing Address
Card Holders Signature	________________________________