Membership Application for PRBAIf you are interested in joining PRBA – The Rechargeable Battery Association, please fill out our online application form for new membership.Company NameCompany Headquarters Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact(s) First Last Contact Address (if different from above address) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TelephoneFaxEmail WebsiteLocation of Company's Major United States Facilities (if applicable)Membership CategoriesACTIVE MEMBERSActive Membership confers voting privileges and is open to any person, firm or corporation engaged in the manufacture, distribution or assembly of rechargeable batteries or battery-operated products. The dues schedule for Active Members, which has been designed to allow participation to companies of all sizes, is as follows:1A. Manufacturers, importers, and affiliated* distributor/assemblers of sealed rechargeable batteries (“batteries”):Combined annual U.S. sales on nickel cadmium (Ni-Cd), nickel metal hydride (Ni-Mh), lithium ion (Li-ion) and other sealed rechargeable battery systems, excluding lead (Pb):DuesSelect Due AmountA1. Greater than $75 million ($45,600.00)A2. $25 - 75 million ($32,300.00)A3. Less than $25 million ($16,200.00)B. Distributors and assemblers of sealed batteries not affiliated* with a sealed battery manufacturer:Combined annual purchase for resale in the U.S. of nickel cadmium (Ni-Cd), nickel metal hydride (Ni-Mh), lithium ion (Li-ion) and other sealed rechargeable battery systems, excluding lead (Pb):DuesSelect Due AmountB1. Greater than $5 million ($23,100.00)B2. $1 - 5 million ($11,300.00)B3. Less than $1 million ($7,200.00)C. Manufacturers, importers, distributors and assemblers of sealed rechargeable battery-operated products:Combined purchases, for sale in battery-powered products sold in the U.S. of nickel cadmium (Ni-Cd), nickel metal hydride (Ni-Mh), lithium ion (Li-ion) and other sealed rechargeable battery systems, excluding lead (Pb):DuesSelect Due AmountC1. Greater than $5 million ($23,100.00)C2. $1 - 5 million ($11,300.00)C3. Less than $1 million ($7,200.00)1 Dues are assessed on an annual basis for the forth-coming calendar year. Dues are prorated for new members joining the association after January 1 of any calendar year.D. Suppliers to the sealed rechargeable battery industry, including recyclers: Total sales in the U.S. or products destined for the U.S.DuesSelect Due AmountD1. Greater than $5 million ($23,100.00)D2. $1 - 5 million ($11,300.00)D3. Less than $1 million ($7,200.00)E. Manufacturers, distributors and assemblers of rechargeable battery powered vehicles (e.g., hybrid-electric vehicles, electric vehicles, mobility devices, self-propelled equipment):Combined purchases or manufacture, for use in full or partially-battery-powered vehicles sold in the U.S., of nickel cadmium (Ni-Cd), nickel metal hydride (Ni-Mh), lithium ion (Li-ion) and other sealed rechargeable battery systems, excluding lead (Pb), valued at the levels specified:DuesSelect Due AmountE1. Greater than $10 million ($28,400.00)E2. $1 - 10 million ($14,000.00)E3. Less than $1 million ($7,200.00)ASSOCIATE MEMBERSAny person, firm or corporation that provides services to persons, firms or corporations that manufacture, distribute, import, assemble, recycle or retail batteries.DuesSelect Due AmountWe wish to become an Associate member ($7,200.00)ELECTRONIC SIGNATUREThe Company identified within applies for membership in the PRBA and agrees to be bound by the Association’s charter, bylaws and rules. We understand that we will be notified upon acceptance of this application and invoiced for payment of annual dues. We agree to comply with any reasonable request from the Association staff for information confirming our appropriate annual dues category, with the understanding that any information provided in response to such inquiry shall be held in strict confidence and not shared with any other Association Member.Authorized Signature First Last Date MM slash DD slash YYYY Contributions of gifts to PRBA are not deductible as charitable contributions for federal income tax purposes. However, they may be tax deductible under other provisions of the Internal Revenue Code.*For purposes of dues categorization, "affiliated" means controlling, controlled by or under common control with a sealed rechargeable battery manufacturer.Total Total Credit CardAmerican ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.