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<p><em>Fields marked with a <span title="Required field" class="required">*</span> are required</em></p>

<form method="post" action="/Help/Account/Request/Member" class="lMargin tMargin" id="request_form">

  <fieldset>
    <label for="given_name"><span title="Required field" class="required">*</span> Given name:</label>
    <input name="given_name" type="text" size="30" value="" id="given_name" />
    <label for="family_name"><span title="Required field" class="required">*</span> Family name:</label>
    <input name="family_name" type="text" size="30" value="" id="family_name"/>
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  <fieldset>
    <label for="email"><span title="Required field" class="required">*</span> Email:</label>
    <input name="email" type="text" size="30" value="" id="email"/>
    <label for="phone_number"><span title="Required field" class="required">*</span> Phone (Use international notation, eg: "+1.617.555.1212" or "+33.4.92.38.75.94 ext. 123"):</label>
    <input type="text" id="phone_number" name="phone_number" size="25" value=""/>
    <select name="phone_type">
<option label="Home" value="Home">Home</option>
<option label="Home Office" value="Home Office">Home Office</option>
<option label="Mobile" value="Mobile">Mobile</option>
<option label="Office" value="Office">Office</option>
<option label="Other" value="Other">Other</option>
</select>

    <input type="checkbox" id="phone_voicemail" name="phone_voicemail" value="1"/><label for="phone_voicemail" style="display: inline">Voicemail</label>
  </fieldset>
  <fieldset>
	  <label for="organization"><span title="Required field" class="required">*</span> I am an employee of the following  <a href="http://www.w3.org/Consortium/Member/List">W3C Member</a>: </label><br />
    <select name="organization" id="organization" size="10">
          <option value="45045">28msec Inc.</option>
          <option value="32971">Aalto University</option>
          <option value="45744">Academia Sinica</option>
          <option value="25377">ACORD Corporation</option>
          <option value="40080">Adesis Netlife S.L.</option>
          <option value="1057">Adobe Systems Inc.</option>
          <option value="51412">AdTruth</option>
          <option value="37773">Afilias Limited</option>
          <option value="43667">Agencia para el Desarrollo del Gobierno de Gestion Electronica y la Sociedad de la Informacion y del Conocimiento (AGESIC)</option>
          <option value="35617">AgileDelta, Inc.</option>
          <option value="39587">Akmin</option>
          <option value="1107">Alcatel-Lucent</option>
          <option value="41961">Alisys Software</option>
          <option value="17365">Altova GmbH</option>
          <option value="37153">AME Info FZ LLC</option>
          <option value="44328">ANBOTO</option>
          <option value="40736">ANDANZA TECHNOLOGIES</option>
          <option value="44294">Aplix Corporation</option>
          <option value="1202">Apple, Inc.</option>
          <option value="44434">association BrailleNet</option>
          <option value="1032">AT&amp;T</option>
          <option value="39840">Atal Behari Vajpayee - Indian Institute of Information Technology and Management, Gwalior</option>
          <option value="41923">Attensity Europe GmbH</option>
          <option value="9918">Australian Government Information Management Office (AGIMO)</option>
          <option value="16174">Avaya Communications</option>
          <option value="38698">Ayuntamiento de Zaragoza</option>
          <option value="49669">Baidu, Inc.</option>
          <option value="50944">BarrierBreak Technologies</option>
          <option value="29696">Bartimeus - Accessibility</option>
          <option value="49902">Basque Government - Irekia</option>
          <option value="37791">Beihang University</option>
          <option value="38522">Beijing University of Technology</option>
          <option value="1130">Bitstream, Inc.</option>
          <option value="50816">BlueCava, Inc.</option>
          <option value="1120">British Broadcasting Corporation</option>
          <option value="1042">BT</option>
          <option value="43599">Business Directory UK</option>
          <option value="41840">Bytemobile, Inc.</option>
          <option value="31922">CA Technologies</option>
          <option value="46045">Cable Television Laboratories Inc</option>
          <option value="45035">CAIXA</option>
          <option value="43847">Cambridge Semantics</option>
          <option value="1147">Canon, Inc.</option>
          <option value="9848">Center for Democracy and Technology</option>
          <option value="45032">Center of Excellence in Wireless &amp; Information Technology (CEWIT) at Stony Brook University</option>
          <option value="37299">Centre for Development of Advanced Computing (CDAC)</option>
          <option value="45448">CENTRE FOR RESEARCH AND TECHNOLOGY HELLAS</option>
          <option value="37971">Centro de Treinamento iLearn</option>
          <option value="35690">Centro Europeo de Estudios y Formaci&oacute;n Empresarial Garrigues</option>
          <option value="1049">CERN</option>
          <option value="51570">Chapell &amp;amp; Associates</option>
          <option value="16509">Chevron</option>
          <option value="39575">China Electronics Standardization Institute</option>
          <option value="44763">China Unicom</option>
          <option value="37846">Chinese Academy of Sciences</option>
          <option value="9961">Cisco</option>
          <option value="39269">Cleveland Clinic</option>
          <option value="42104">Clinical and Biomedical Computing Ltd</option>
          <option value="9850">CNR--Consiglio Nazionale delle Ricerche</option>
          <option value="51903">Cocomore AG</option>
          <option value="42239">College of American Pathologists</option>
          <option value="40014">College of Computer and Software Engineering in Taiyuan University of Technology (TYUT)</option>
          <option value="46824">Comcast Cable Communications, LLC</option>
          <option value="50818">Cox Communications, Inc.</option>
          <option value="34656">Creative Commons</option>
          <option value="9923">CSIRO</option>
          <option value="1024">CWI</option>
          <option value="16322">DAISY Consortium</option>
          <option value="40187">Data Recovery Software</option>
          <option value="1219">Defense Information Systems Agency (DISA)</option>
          <option value="45802">Department of Health and Human Services</option>
          <option value="39579">Department of Informatics, PUC-Rio</option>
          <option value="37458">Department of Information Technology, Government of India</option>
          <option value="44765">Department of Internal Affairs</option>
          <option value="38621">Deque Systems, Inc.</option>
          <option value="35429">DERI Galway at the National University of Ireland, Galway, Ireland</option>
          <option value="35468">Design Science, Inc.</option>
          <option value="42051">Deutsche Natinalbibliothek (DNB)</option>
          <option value="9824">Deutsche Telekom AG</option>
          <option value="39100">DigiCert SSL Certificate Authority</option>
          <option value="39548">Disruptive Innovations</option>
          <option value="38695">Dreamlab Technologies AG</option>
          <option value="48275">dynaTrace software Inc.</option>
          <option value="12480">Ecole Mohammadia d'Ingenieurs Rabat (EMI)</option>
          <option value="43576">Ecole Superieure Polytechnique</option>
          <option value="50114">Effective Measure</option>
          <option value="39091">Eindhoven University of Technology</option>
          <option value="28169">Electronics and Telecommunications Research Institute (ETRI)</option>
          <option value="41484">Eli Lilly and Company</option>
          <option value="51764">eMagenationStudios</option>
          <option value="40313">EMC Corporation</option>
          <option value="43514">Energistics</option>
          <option value="51496">ENLASO Corporation</option>
          <option value="1205">ERCIM</option>
          <option value="9826">ERICSSON </option>
          <option value="50403">ESOMAR World Association for Social, Market and Opinion Research</option>
          <option value="43951">European Broadcasting Union (EBU-UER)</option>
          <option value="47163">eXa - online</option>
          <option value="46877">Facebook</option>
          <option value="38714">FinanzNachrichten.de</option>
          <option value="41261">FLWOR Foundation</option>
          <option value="43422">Formations House</option>
          <option value="6383">Forschungszentrum Informatik (FZI)</option>
          <option value="37314">Fotosearch Stock Photography and Footage</option>
          <option value="1108">Foundation for Research and Technology - Hellas(FORTH)</option>
          <option value="1052">France Telecom</option>
          <option value="1117">Fraunhofer Gesellschaft</option>
          <option value="35615">Free University of Bozen-Bolzano</option>
          <option value="9949">FSTC (Financial Services Technology Consortium)</option>
          <option value="1183">Fujitsu Limited</option>
          <option value="47202">Fundacion BiscayTIK - BiscayTIK Fundazioa</option>
          <option value="33823">Fundacion CTIC</option>
          <option value="34901">Fundaci&oacute;n ONCE</option>
          <option value="51606">Future of Privacy Forum</option>
          <option value="44649">Future Technology Laboratories Inc.</option>
          <option value="35552">Futuver Consulting</option>
          <option value="38987">Garlik</option>
          <option value="50353">Gemalto SA</option>
          <option value="19161">Genesys Telecommunications Laboratories</option>
          <option value="26550">German Research Center for Artificial Intelligence (DFKI) Gmbh</option>
          <option value="42586">Gobierno del Principado de Asturias</option>
          <option value="35662">Google, Inc.</option>
          <option value="6283">Health Level Seven, Inc.</option>
          <option value="39112">HiSoftware Inc.</option>
          <option value="1142">Hitachi, Ltd.</option>
          <option value="41612">HOB GmbH &amp; Co. KG</option>
          <option value="45217">Hochschulbibliothekszentrum des Landes NRW</option>
          <option value="1079">HP</option>
          <option value="49753">Huawei</option>
          <option value="38525">IBBT</option>
          <option value="1051">IBM Corporation</option>
          <option value="38683">iFLYTEK</option>
          <option value="14893">Ikivo AB</option>
          <option value="39168">IKM Internet Kaufmarkt GmbH</option>
          <option value="37804">Image, Video and Multimedia Systems Lab (IVML-NTUA)</option>
          <option value="9873">Industrial Technology Research Institute (ITRI)</option>
          <option value="9999">Infopark AG</option>
          <option value="46179">Infraware, Inc</option>
          <option value="50678">Innovative Idea Group</option>
          <option value="38998">INNOVIMAX</option>
          <option value="36231">INSTITUT  TELECOM</option>
          <option value="10894">Institut National de Recherche en Informatique et en Automatique (INRIA)</option>
          <option value="37469">Institute of Informatics &amp; Telecommunications (IIT), NCSR</option>
          <option value="43981">Instituto Nacional de Tecnologias de la Comunicacion, S.A.</option>
          <option value="9829">Intel Corporation</option>
          <option value="50221">Interactive Advertising Bureau (IAB) Europe</option>
          <option value="9928">International Webmasters Association / HTML Writers Guild (IWA-HWG)</option>
          <option value="17652">Internet Academy, Inc.</option>
          <option value="34174">Inventive Designers n.v.</option>
          <option value="50755">Iran Web Festival</option>
          <option value="45737">Iranian Consortium of National Content</option>
          <option value="42318">Israel Internet Association (isoc-il)</option>
          <option value="43656">ISTIC</option>
          <option value="35681">Istituto per la Ricerca, la Formazione e la Riabiltazione - Onlus (I.Ri.Fo.R.)</option>
          <option value="37901">Jataayu Software</option>
          <option value="44588">jig.jp co.,ltd.</option>
          <option value="43769">JOANNEUM RESEARCH Forschungsgesellschaft mbH</option>
          <option value="1121">Joint Info. Systems Comm. of the UK Higher Ed. Funding Council (JISC)</option>
          <option value="38528">Jozef Stefan Institute</option>
          <option value="42701">Kaiser Permanente</option>
          <option value="47581">KDDI CORPORATION</option>
          <option value="10911">Keio University</option>
          <option value="42834">Larson Software Technology</option>
          <option value="1015">Lawrence Berkeley National Laboratory</option>
          <option value="45326">Layar</option>
          <option value="45096">LG Electronics</option>
          <option value="7552">Library of Congress</option>
          <option value="43572">LINK Development</option>
          <option value="47063">LINKatu</option>
          <option value="14585">Loquendo, S.p.A.</option>
          <option value="9878">Los Alamos National Laboratory</option>
          <option value="51637">Lucy Software and Services GmbH</option>
          <option value="28578">MarkLogic</option>
          <option value="42913">Mayo Clinic</option>
          <option value="43273">Media Access Australia</option>
          <option value="39487">Meraka Institute</option>
          <option value="41727">Metatomix inc</option>
          <option value="1066">Microsoft Corporation</option>
          <option value="42474">MIMOS BHD</option>
          <option value="38857">MIND Center for Interdisciplinary Informatics</option>
          <option value="37877">Ministerio de Administraciones P&uacute;blicas</option>
          <option value="10892">MIT</option>
          <option value="1092">MITRE Corporation</option>
          <option value="35668">Mitsue-Links Co., Ltd.</option>
          <option value="44277">MLstate</option>
          <option value="41489">Mobile Web Forum</option>
          <option value="46784">Mobilizy</option>
          <option value="47376">Mondeca</option>
          <option value="43051">Monotype Imaging Inc.</option>
          <option value="51641">Moravia Worldwide</option>
          <option value="47644">Motorola Mobility, Inc.</option>
          <option value="51608">MovieLabs</option>
          <option value="35507">Mozilla Foundation</option>
          <option value="48273">MStar Semiconductor, Inc.</option>
          <option value="9882">MTA SZTAKI</option>
          <option value="47785">National Aeronautics and Space Administration</option>
          <option value="33654">National Association of Convenience Stores (NACS)</option>
          <option value="45455">National Cancer Institute (NCI)</option>
          <option value="39297">National ICT Australia (NICTA) Ltd</option>
          <option value="43267">National Institute of Informatics</option>
          <option value="26556">National Institute of Standards and Technology (NIST)</option>
          <option value="14771">National Research Council Canada</option>
          <option value="48668">National Research University 'Higher School of Economics' - Centre of Semantic Technologies</option>
          <option value="45273">NEC Corporation</option>
          <option value="46378">Netflix Inc.</option>
          <option value="40730">New Zealand State Services Commission</option>
          <option value="39368">NexTag, Inc.</option>
          <option value="41986">Nextstage Corporation</option>
          <option value="51472">NHK (Japan Broadcasting Corporation) </option>
          <option value="51072">NIA(National Information Society Agency)</option>
          <option value="39493">NIC.br - Brazilian Network Information Center</option>
          <option value="9833">Nippon Telegraph &amp; Telephone Corp. (NTT)</option>
          <option value="1105">Nokia Corporation</option>
          <option value="39018">Nominet</option>
          <option value="42792">Novartis Pharma AG</option>
          <option value="35521">NRCD Research Institute (National Rehabilitation Center for Person with Disabilities)</option>
          <option value="9922">NTT DoCoMo</option>
          <option value="14285">Nuance Communications, Inc.</option>
          <option value="9977">OASIS (Organization for the Advancement of Structured Information Standards)</option>
          <option value="1177">Object Management Group, Inc. (OMG)</option>
          <option value="1187">OCLC (Online Computer Library Center, Inc.)</option>
          <option value="7071">Office of the Government Chief Information Officer (OGCIO)</option>
          <option value="45033">Oficina Presidencial de Tecnologias de la Informacion y Comunicacion (OPTIC)</option>
          <option value="50675">Online Publishers Association</option>
          <option value="47357">Ontos AG</option>
          <option value="43103">Ontotext</option>
          <option value="39381">Open Geospatial Consortium</option>
          <option value="39619">OpenLink Software Inc.</option>
          <option value="34067">Openstream, Inc.</option>
          <option value="1149">Openwave Systems Inc.</option>
          <option value="7271">Opera Software</option>
          <option value="1088">Oracle Corporation</option>
          <option value="39775">Ordnance Survey</option>
          <option value="44230">ORO Co., Ltd</option>
          <option value="47188">Pacific Northwest National Laboratory</option>
          <option value="1190">Partners HealthCare System, Inc.</option>
          <option value="43842">PayPal, Inc.</option>
          <option value="38151">Pfizer Inc</option>
          <option value="13686">Presidenza del Consiglio dei Ministri</option>
          <option value="15836">Profium Ltd.</option>
          <option value="28074">Progeny Systems</option>
          <option value="40879">Prometheo</option>
          <option value="38147">PTC-Arbortext</option>
          <option value="44038">Qualogy</option>
          <option value="11870">Raining Data Corporation</option>
          <option value="47545">Rakuten,Inc.</option>
          <option value="42246">Redhat</option>
          <option value="34023">RenderX</option>
          <option value="41999">Rensselaer Polytechnic Institute</option>
          <option value="32788">Research In Motion, Ltd. (RIM)</option>
          <option value="45842">Revelytix, Inc.</option>
          <option value="50929">RIA Novosti</option>
          <option value="44447">RightClick Limited</option>
          <option value="42300">Rochester Institute of Technology</option>
          <option value="1027">Royal National Institute of Blind People (RNIB)</option>
          <option value="40030">Samsung Electronics Co., Ltd.</option>
          <option value="38679">SandCherry, Inc.</option>
          <option value="47112">SanDisk Corporation</option>
          <option value="37946">Sandpiper Software, Inc.</option>
          <option value="1210">SAP AG</option>
          <option value="47941">School of Computing Science, Newcastle university</option>
          <option value="42147">Semantic Universe</option>
          <option value="45805">Senac Sao Paulo</option>
          <option value="34924">Seresco, S.A.</option>
          <option value="42908">SERPRO (Brazilian Federal Agency of Information Technology)</option>
          <option value="42656">SFR</option>
          <option value="1077">SICS</option>
          <option value="12390">Siemens AG</option>
          <option value="39024">SK Telecom</option>
          <option value="51340">Smart Communications Inc.,</option>
          <option value="34909">Sociedad Asturiana de Diversificaci&oacute;n Minera S.A. (SADIM S.A.)</option>
          <option value="50768">Socrata</option>
          <option value="6276">Software AG</option>
          <option value="46141">Sony Corporation</option>
          <option value="43183">Sony Ericsson Mobile Communications AB</option>
          <option value="36697">SRI International</option>
          <option value="39791">Stadt Branchenbuch GmbH</option>
          <option value="29822">Stanford University</option>
          <option value="1060">SURF net bv</option>
          <option value="38262">Syncro Soft</option>
          <option value="28957">Syntellect Inc.</option>
          <option value="35459">Talis Group Ltd</option>
          <option value="32610">Tampere University of Technology</option>
          <option value="37898">Telecom Italia SpA</option>
          <option value="34965">Telef&oacute;nica de Espa&ntilde;a, SAU</option>
          <option value="51643">Telenor</option>
          <option value="42523">The American Institute of Architects</option>
          <option value="43420">The Apache Software Foundation</option>
          <option value="1143">The Boeing Company</option>
          <option value="42273">The National Archives</option>
          <option value="50279">The Nielsen Company</option>
          <option value="37224">The Open University</option>
          <option value="37883">The Walt Disney Company</option>
          <option value="41606">Third Party Formations Limited t/a The Company Warehouse</option>
          <option value="34320">Thunderhead Ltd.</option>
          <option value="17654">TIBCO Software Inc.</option>
          <option value="9954">TNO Telecon</option>
          <option value="45176">Tomo-Digi Corporation</option>
          <option value="39354">TopQuadrant</option>
          <option value="9842">Toshiba Corporation</option>
          <option value="50112">TRUSTe</option>
          <option value="40140">TSSG</option>
          <option value="47475">U.S. Environmental Protection Agency</option>
          <option value="51721">UCWEB</option>
          <option value="35719">Universidad de Oviedo</option>
          <option value="34345">Universidad Polit&eacute;cnica de Madrid</option>
          <option value="41905">Universitat Polit&egrave;cnica de Catalunya</option>
          <option value="39895">Universit&eacute; catholique de Louvain</option>
          <option value="47373">Universit&eacute; de Lyon</option>
          <option value="38571">University of Aberdeen, Computing Science</option>
          <option value="37633">University of Amsterdam</option>
          <option value="43544">University of Applied Sciences Potsdam</option>
          <option value="51636">University of Economics, Prague</option>
          <option value="9963">University of Edinburgh (School of Informatics)</option>
          <option value="31918">University of Helsinki</option>
          <option value="51785">University of Limerick</option>
          <option value="36643">University of Manchester</option>
          <option value="41719">University of Oxford</option>
          <option value="1163">University of Southampton</option>
          <option value="48543">Universit&auml;t Ulm</option>
          <option value="43944">Venafi</option>
          <option value="51668">Verisign, Inc.</option>
          <option value="33727">Vision Australia</option>
          <option value="35085">Vodafone</option>
          <option value="16050">Voxeo Corporation</option>
          <option value="29386">Voxpilot Ltd.</option>
          <option value="16188">Vrije Universiteit</option>
          <option value="9926">Waterloo Maple Inc.</option>
          <option value="7211">Web3D Consortium</option>
          <option value="42668">Wholesale Applications Community (WAC)</option>
          <option value="45651">World Wide Web Foundation</option>
          <option value="40047">Wright State University</option>
          <option value="38241">WSO2</option>
          <option value="37526">Xerox Corporation</option>
          <option value="37248">Yahoo!, Inc.</option>
          <option value="42484">Yale SenseLab</option>
          <option value="44233">Yantra Software Pvt Ltd</option>
          <option value="44690">Zhejiang University</option>
          <option value="46401">Zynga Inc.</option>
        </select>
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