Apply for Membership

Business Information

Business Name

DBA Name

Address

Phone

Website

Tax ID

State of Incorporation

Member Segment

Annual Revenue

How did you hear about us?

Employee Representatives

Please list the employee(s) that will represent this business to the Forum. Only one individual may vote on behalf of the business.

Designated Voter - Primary Contact

Full Name

Title

Email Address

Office Phone

Cell Phone

LinkedIn URL

Alternate Contact

Full Name

Title

Email Address

Office Phone

Cell Phone

LinkedIn URL

Representations and Signatures

I certify that my answers are true and complete to the best of my knowledge. I certify that I am both employed by and authorized to submit this application of behalf of the business named above.

I agree to adhere to the bylaws of the DSA Stablecoin Forum. I understand that providing false or misleading information in my application may result in rejection of our application.

Signature

Title

Date