Membership Application - Blockchain for Social Impact

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Membership Applicationwpengine2018-11-30T20:39:45+00:00

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Membership Application

Organization Information

Organization Name:

Organization Address:

Organization URL:

Address

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Contact Information

Primary Contact Name:

Title:

Address:

Email:

Phone:

Fax:

Alternate Business Contact

Name:

Title:

Address:

Email:

Phone:

Fax:

Application Questions

Membership Level *

Founding Member - (price: $15,000)

Technology Member - >$10M annual revenue or assets - (price: $7,500)

Technology Member - $2M - $10M annual revenue or assets - (price: $2,500)

Technology Member - <$2M annual revenue - (price: $500)

Social Impact Member - (price: $500)

Individual Member - (price: $150)

BSIC is a member community and we hope that membership will be willing to participate in supporting the community. In which ways would your organization willing to offer community support?

Sponsorship

Expertise

Mentoring

Payment in kind

Working group champion

Design services

Other

What type of organization describes your organization:

Non-Governmental Organization

Enterprise

Foundation

Blockchain Venture

Impact Investment Organization / Fund

Other

Founding Member

If selected Non-Governmental Organization, Enterprise or Foundation, please answer yes/no to the following:

Is your organization interested in collaborating with others in the social impact space? If yes, please describe what type of partnership would you be interested in.

Yes

No

If yes, please describe in the field below

Where does your organization fall within the blockchain for social impact journey with Ethereum?

Exploring potential solutions

Looking to learn about the potentials

Looking to develop a solution and your organization has dedicated funding

In development

As a member of BSIC, my organization is willing to work with the technologists/social entrepreneurs to develop Concepts, Use Cases, and Product Market of a blockchain solution.

Yes

No

My organization is already funding, developing, or deploying a blockchain solution, or has a very clear roadmap for doing so in the near future.

Yes

No

Which of the following will your organization satisfy? Select all that apply.

A viable blockchain solution with foreseeable impact

A strong team with exceptional execution capability

A well-established organization with a developed client base

Willing to pitch in speakers, venues, thought leadership, sponsorship dollars, in-kind donation, etc.

Complementary to and willing to collaborate with existing members

What is the focus of the social impact project(s) that you are currently working on? Please provide details on what the project is along with a brief description, outcome and geography.

Is there a direct mandate from your c suite to engage in block for social impact decisions?

Yes

No

Not sure

What role do you play in your organizations ability to make funding decisions in blockchain?

Influencer

Decision maker

OtherOther

If you are human, leave this field blank.

About Us

Blockchain for Social Impact

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