Section A: Contact Details - Download as DOC by S888vInM


									                                                                            CORPORATE APPLICATION FORM
                                                                                  HIC & LIC MEDIUM 2012
                                                                                           Ref. WEB 2012

M E D I U M C or p or a t e M e mb e r s hi p
           5 0 – 5 0 0 p r o f e s s i o n a l e m p l o ye e s w o rk i n g i n t h e w a t e r d i vi s i o n o f y o u r c o mp a n y
B e ne fi ts i n c l ud e t he f ol l ow i ng:
           W a t e r2 1 – me m b e rs h i p m a g a zi n e (6 i s s u e s p e r y e a r)
           IW A Ye a r b o o k
           S p e c i a l i s t G ro u p p a rt i c i p a t i o n – a n y n u m b e r o f g r o u p s
           Di s c o u n t o n IW A P u b l i s h i n g b o o k s ( 2 5 %)
           Di s c o u n t o n IW A c o n f e re n c e , w o rk s h o p a n d s e mi n a r re g i s t r a t i o n f e e s
           Di s c o u n t (2 5 % ) o n P a y - p e r - vi e w a r t i c l e s
           Tw o fr e e pr i n t s ub s c r i pt i o ns to I W A P ub l i s hi ng j ou r n a l s o f yo ur c h oi c e
           T e n no m i n a t e d r e pr e s e n ta ti v e s – s e e a t t a c h e d f o r m

Section A: Contact Details

Please complete the appropriate sections and boxes CLEARLY and in BLOCK CAPITALS.

Company Name
                                                                                 Please select ONE that most accurately describes your
Company Address

Town / City                                                                        Type of Organisation
Postcode / Zip                                                                          Research Institute [W1]       Technology Suppliers [W3]
Country                                                                                                               Large Water Using
                                                                                       Consultancy [W4]
                                                                                                                      Industry [W5]
Telephone                     +
                                                                                      Utility                        Governmental Organisation
2nd Phone No                  +                                                    Public [W2]                    Regulator [W7]
Website                                                                            Private [W14]                  Local Government [W11]
                                                                                                                  Regional Government [W12]
Strategic Contact*
                                                                                                                  National Government [W13]
Email                                                                                  Multilateral Agency (e.g Regional Banks, UN Agency) [W9]
Telephone No                                                                            NGO (e.g Charity, Association) [10]
Admin Contact**                                                                         Other [W8]
Telephone No
Human Resources
Contact                                                                                Please tick this box if you DO NOT wish to have your
Email                                                                               contact details printed in the IWA Yearbook.

Telephone No

  * The strategic contact should be at the level of Management Director or CEO in your organisation. This contact will be
  sent copies of IWA W21 magazine as part of your corporate membership package.
  ** The admin contact is who assists in the handling and administration of your membership.

Section B: Membership

The MEDIUM corporate membership fees for both High and Low Income Countries, for the year 2012 (Jan-Dec) are listed below. Your
country classification (High or Low) is based on your country of residence and a listing can be found on the IWA website together with more information on IWA’s programme of activities and corporate membership benefits.

Subscribe to IWA Membership for a period of three years and you can benefit from a 10% discount on your membership fee. Please
note that you will still be contacted separately each year regarding your choice of journal subscription.

                                                       High Income Country                               Low Income Country

              One Year (2012)                              £927/ US$1,634 / €1,225                           £464 / US$817 / €613

              Three Years (2012 - 2014)                    £2,503/ US$4,412 / €3,308                         £1,253 / US$2,206 / €1,655

                                                                CORPORATE APPLICATION FORM
                                                                      HIC & LIC MEDIUM 2012

IWA Global Development Challenge Fund

It is now possible to make an additional contribution to the IWA Global Development Challenge Fund, which is dedicated to IWA’s
programme on regional development in low and middle income countries. For further information please visit

         IWA Global Development Challenge Fund                  £500 / US$1,000/ €650 s u g ge s t e d mi n i mu m
         Contribution Jan – Dec 2012                            Other Amount ____________

Section C: Journal Subscriptions

As a MEDIUM corporate member you are entitled to receive TWO FREE print subscriptions to the IWA Publishing journals of your
choice, please indicate these on the list below. Subscriptions to any additional journals including online access will be at the 10%
discounted rate. The journal subscriptions will be valid for ONE year, between the period January to December 2012. Journals will
need to be renewed on an annual basis. Refunds on journal subscriptions and membership fees will not be accepted after 30 days
from the date of receiving your payment. Additional information about the journals can be obtained from If you
require the online version of a journal, please contact Marketing at IWA Publishing on

                                                                      ONE FREE           10% Discounted Rate
        Member Journal Subscriptions
                                                                       (Print)           (print and online)
        Water, Science and Technology*                                                  £3,883 / US$7,140 / €5,979 / ¥ 836,527
        Water, Science and Technology: Water Supply                                     £1,339 / US$2,370 / €2,164 / ¥ 267,899
        Journal of Water Supply: Research & Technology – AQUA                           £635 / US$1,086 / €917
        Water Policy                                                                    £685 / US$1,331 / €1,076
        Journal of Water and Health                                                     £693 / US$1,252 / €1,022
        Journal of Hydroinformatics                                                     £454 / US$802 / €707
        Hydrology Research                                                              £441 / US$756 / €662
        Journal of Water & Climate                                                      £403 / US$598 / €505
        Water Practice and Technology – Online Only                                     £185 / US$350 / €268
        Water Intelligence Online – Online Only                                         £1,557 / US$2,949 / €2,264
        Water, Sanitation and Hygiene for Development                                   £379 / US$599 / €474
        Journal of Reuse and Desalination                                               £379 / US$599 / €474
        Water Research**
        ***Water Asset Management
                                                                                        £217 / US$432 / €327
        International –                  Print     OR Online
        ***Water Utility Management
                                         Print     OR Online                            £203 / US$406 / €307
        International –

         *Corporate members in Low Income Countries that choose to receive free the Journal Water, Science & Technology will
          receive online access (instead of a print copy of this Journal).
         **For new subscriptions to the journal Water Research, please contact Elsevier Science directly on Tel: +31 (0) 20 485
          3757, Fax: +31 (0) 20 485 3432 or email:
         *** Please indicate if you wish to receive either the print or online version of Water Asset Management International (WAMI)
          and/or Water Utility Management International (WUMI).

For additional subscriptions, corporate members receive a special offer price of 25% discount off the full institutional price for
online only, not including print Journal. This exclusive offer is for IWA corporate members only. For more details please contact
Marketing at IWA Publishing on

Section D: Nominated Representatives

Nominated Representatives are the TEN key employees in your company who will receive benefits including Water21, the IWA
Yearbook and membership to Specialist Groups. Please find attached an additional form to be completed by each of your nominated
representatives. Please complete and return these to IWA at the earliest convenience in order for these individuals to have access to
the membership benefits.

                                                                CORPORATE APPLICATION FORM
                                                                      HIC & LIC MEDIUM 2012

Section E: Payment Details

Please add together the costs of the items you have selected:

        Section B: Membership
        Section B: Global Development
        Challenge Fund
        Section C: Journal Subscriptions

* Refunds on membership fees and journal subscriptions will not be accepted after 30 days from the date of receiving your payment.


Please tick your preferred method of payment. Payment should be made in £ sterling, US $ or € Euros. Please ensure that your
payment includes all bank charges.

                                       Make payment to ‘International Water Association’, HSBC Bank. Account # 41463829 –Sort
                                       Code: 40-07-13 IBAN: GB61 MIDL 40071341463829, Swift Code: MIDLGB22 Bank address:
   Bank Transfer
                                       HSBC Plc. Victoria Street, London SW1H 0NJ, UK (Please state your company name and
                                       reason for transfer as ‘IWA Membership’)

   Cheque or Postal Order              Cheque made payable to ‘International Water Association’

   Credit Card Payment
                                       Card Type:                                    Card Number:
  (AMEX not accepted)
                                       Expiry Date:                                  Valid From:
                                       Name of Card Holder:                          Signature:

                                             Please complete the form and return to:
                                       IWA, Membership Department, Attn: Roselyn Chang,
                                   Koningin Julianaplein 2, 2595 AA, The Hague, The Netherlands
                                         Tel: +31 70 31 50 783    Fax: +31 (0)70 347 7005
                                     Email: /


To top