Corporate Membership Enter details FinTech Australia will contact you once this form is received to discuss approval of your membership application. Membership Type by Company size (number of full time employees)*Self-employed / Principals only ($550)Under 30 FTEs ($5,500)30+ FTEs ($16,500)Name* First Last Preferred Job TitleThis person will be our primary contact and will receive the membership invoice. Email* Primary Contact Number*Company name*Company URL* Office Phone Number*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Company Twitter HandleWill be used to tag your company in postsCompany Facebook URL Company Linkedin Profile NameCompany DescriptionThis may be used for promotional purposes 100 wordsMicro PitchWhat do you do? (in under ten words)Best person to contact for business development opportunities?Include full name; email address; phone numberWhat kind of FinTech company are you? (choose up to 3)*Member characterisation will be aligned with the ecosystem map. Wealth and investment Asset management and trading Digital/Crypto currencies and exchanges Lending Payments, wallets and supply chain Insurtech Real estate tech HR tech Regtech Identity, security and privacy Incubator/co-working Accelerator/venture capital Data, analytics and information management Business tools Hardware and wearables Challenger/neo bank Marketplace-style or peer-to-peer solution Crowdfunding/fractionalised investing Blockchain/distributed ledger solution Other (please specify) Other - Please describe belowDisclaimer*By Submitting this form you agree that all details supplied are correct. You will also receive our member exclusive newsletters. Please note - if you do not meet the requirements of the category selected or if your circumstances change FinTech Australia will get in touch to discuss updating your application. I Agree Pay by*Credit CardBank Transfer (Send me the invoice first)Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Thank you for applying to join our membership! We look forward to working with you to build a collaborative and healthy fintech ecosystem! This iframe contains the logic required to handle AJAX powered Gravity Forms.