SMPTE Registration Authority, LLC

3 Barker Avenue
White Plains, NY 10601 USA
Tel: +1 914 761 1100
Fax: +1 914 761 3115
email: registrar@smpte.org

Application for Registration of UMID Data

This is a fully functional application form. It sends an electronic message to SMPTE Registration Authority, LLC Headquarters which will be processed upon receipt of registration payment. Your processed application will be acknowledged by e-mail.

1. Contact information of organization requesting a Registration

Organization Name::

Address:

Telephone:

Fax:

E-mail:

2. Requested Country Code, Organization Code or Freelance Operator Code

3. Authorized representative

Name:

Title:

Address:

Signature ______________________________________________

4. For official use only of the Registration Authority

Registration rejected: _______

Reason for rejection of the application:

Registration granted: ________ Registration value: ______________

Payment

The one-time registration fee is $2000.00 U.S. per identifier registered.

I wish to pay by credit card on this form. I understand this method is unsecured and I am sending credit card information at my own risk.
Check card type:
American Express MasterCard Visa

Cardholder name:


Credit card number:


Expiration date:

I wish to pay by credit card (American Express, MasterCard, Visa); I'll fax my name, card number and expiration date to SMPTE +1 914 761 3115.

I'll mail a check (payable in U.S. Bank) to SMPTE, 3 Barker Avenue Avenue, White Plains, NY 10601 USA.

NOTE: Registration is not effective until approval and receipt of payment at SMPTE Headquarters.

This form may also be downloaded, printed and then faxed with credit card information to SMPTE at +1 914 761 3115



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2006-07-17
CVG