Axelera membership form 2017 Company name
Yüklə 98,59 Kb.
|
- Bu səhifədəki naviqasiya:
- AXELERA - Membership form 2017 Company name
- Representative at Axelera General Assembly: (AXELERA representative)
- National Membership 2017 Amount excl. VAT
- Financial partners and associate members (
- International membership (members without operations in France) 2017 Amount excl. VAT
- * International companies
- AXELERA Céline GOBIN Rond-point de l’échangeur – Les Levées 69360 Solaize • France
- In………………………………… Date ………………………………… Signature and company stamp of member
- YOUR COMPANY/ORGANISATION
- INTEREST IN ECO-SYSTEMS
- YOUR EXPECTATIONS IN TERMS OF OUR SERVICE OFFERING
- CONTACTS Accounts / Administration
- International operation contacts
- FOR COMPANIES (RD and Training Centres skip to page 7 - Institutional partners skip to page 8) Owned by a group
- RD investment (in €K)
- Is your company a start-up
- Do you have export activities
- Percentage of sales to export markets
- For research laboratories
- what types of training do you propose
- For all: do you belong to European and/or International network involved in chemistry and the environment
- FOR INSTITUTIONAL MEMBERS, PARTNERS AND ASSOCIATE MEMBERS Do you belong to European and/or International networks involved in chemistry and the environment
- Association governed by law of 1901 – SIRET 485 210 082 00031– APE code 9499Z
  AXELERA - Membership form 2017
Company name: SIRET No.: ……………………………………………………… Personnel: ………………………………….....….. Telephone…………………………….….Fax……….............................Website……………………………….…... Address ………………………………………………………………………………………………………….……….. Post code…………………………………………Town/City: . E-mail (generic): . Representative at Axelera General Assembly: (AXELERA representative) Last name / First name……………………………………… Position……………………………………………………. Tel. (mobile)…………………………………..……Email………………………………………………………………..….
Please complete this form and return it to us signed along with your payment to Axelera to the following address: AXELERA Céline GOBIN Rond-point de l’échangeur – Les Levées 69360 Solaize • France Tel : 04.28 27 04 83 www.axelera.org - info@axelera.org Payment can be made by cheque or by wire transfer. Please contact us to get our banking information. I declare my wish to become a member of Axelera. To this end, I acknowledge receipt of the statutes. I hereby undertake to pay an annual membership fee for 2017 within one month of the Association's request for membership fees. My membership will be extended annually by tacit agreement. Membership implies respect of the statutes, which are available to the member at the association's head office or on the website www.axelera.org, respect of the internal regulations and framework agreement, available on request from Axelera. In………………………………… Date ………………………………… Signature and company stamp of member The information we request is required for your membership. Such information is processed for the purposes of administering the association and contacting its members. In accordance with the French data protection act and by application of articles 39 and following of the amended law of 6 January 1978, you have the right to access and rectify any personal information we hold. Should you wish to exercise this right and obtain such information, please write to us at Association AXELERA, La Cité des Entreprises, 66 avenue Jean Mermoz – 69351 LYON Cedex 08 France. For legitimate reasons, you may also oppose the use of any of your personal data. The association consolidates this information for use by its members on its website www.axelera.org (in particular the company/organisation name and the contact person). Your agreement to this publication is considered to be given when becoming a member of the association. You may nonetheless express your wish to cease the publication of this information at any time in the future. To do so, please write to Association AXELERA, La Cité des Entreprises, 66 avenue Jean Mermoz – 69351 LYON Cedex 08 France. INFORMATION FORM To make the best possible use of the services offered by AXELERA we ask you to take 10 minutes to complete this information form. It will enable us to focus on your needs and requirements better. We thank you in advance. The AXELERA team P.S. If you encounter difficulties in filling out this form, please contact us: celine.gobin@axalera.org – Tel: +33 (0)4 28 27 04 89 YOUR COMPANY/ORGANISATION: Date created (year): …………… International VAT identifier: ………………………………………………………..… Total staff headcount:………………….. R&D staff headcount:………………….. Sales (2011) in €K: ……………….
Presentation:…………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………. Principal activity: (please tick one box only) Industrial Engineering / Design work Industry - Chemistry Industry - Chemical applications Environmental technologies Analysis - Instrumentation Environmental Engineering / Design work Recycling / Waste processing Industry - Energy Services Other industries
Industry - Chemistry Industry - Chemical applications Environmental technologies Analysis - Instrumentation Chemistry equipment supplies Environmental Engineering / Design work Recycling / Waste processing Industry - Energy Services Other industries
INTEREST IN ECO-SYSTEMS Eco-designed processes Water, air, soil, agri-agro Bio-resources Materials, recycling, waste Sustainable construction Transport Decarbonised energies INTEREST IN MARKETS Construction Transport Energy Textile Packaging Cosmetics Intermediate goods Sports & leisure Agri-food Pharmaceutical Others (please clarify): ……………………………………………………………………………… YOUR EXPECTATIONS IN TERMS OF OUR SERVICE OFFERING ACCESS TO THE AXELERA NETWORK FINANCIAL ASSISTANCE FOR R&D AND INNOVATION Funding for R&D projects Company financing COMMERCIAL DEVELOPMENT ASSISTANCE - CONSULTING – TRAINING Launch of R&D projects Monetisation of projects and innovation Strategic business consulting Business Intelligence International Development ACCESS TO DEDICATED MAJOR EQUIPMENT (e.g.: INDEED Institute project, AXEL'ONE platform, etc.) OTHER (please clarify): ……………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Last name / First name……………………………………… Position……………………………………………………. Address (if different from above): …………………………………………………………………………………..……… ………………………………………………………………………………………….………………………………………. Tel:……………………………………….…..…… Fax: ………………………………………………….………………….. Email:…………………………………………………………………………………………………………..……………….. International operation contacts: Last name / First name……………………………………… Position……………………………………………………. Address (if different from above): ……………………………………………………..…………………………………… ……………………………………………………………………………………………….…………………………………. Tel:…………………………………………………………Mobile: …………………………………………………………. Email:…………………………………………………………………………………………………….…………………….. R&D contact Last name / First name……………………………………… Position……………………………………………………. Address (if different from above): ………………………………………………..………………………………………… ……………………………………………………………………….…………………………………………………………. Tel:…………………………………………………………Mobile: …………………………….……………………………. Email:……………………………………………………………………………………………….………………………….. Training / HR contact Last name / First name……………………………………… Position……………………………………………………. Address (if different from above): ………………………………………………..………………………………………… …………………………………………………………………………………………………….……………………………. Tel:…………………………………………………………Mobile: …………………………………………………………. Email:……………………………………………………………………………………………………….………………….. Other contacts Last name / First name……………………………………… Position……………………………………………………. Address (if different from above): ………………………………………………...………………………………………… ……………………………………………………………….…………………………………………………………………. Tel:…………………………………………………………Mobile: ………………………………….………………………. Email:………………………………………………………………………………………………………………….……..
If yes, name of Group: ………………………………………………………………………………………………………….. % owned by group: < 30% of capital 30% Nationality of Group: Group consolidated sales: ……………………………………….. Total group employee headcount: ………………………… Group R&D headcount: ……………………………………………….
For 2011:…………………… For 2010: ………………. For 2009: ………………….. For 2008: ……………………. What other sites do you have in Rhône-Alpes? R&D centre City:…………………………………………………… Production site City:………………………………………… Laboratory City:………………………………………… Commercial office City:………………………………………… Other: …………… City:………………………………………… Is your company a start-up? Yes No Is your company recognised as JEI* (Young Innovative Business)? Yes No Has your company been assisted by an incubator? Yes No If yes please indicate which: …………………………………………………………………………………………………
If yes to which countries: Europe: Germany Austria Belgium Bulgaria Cyprus Denmark Spain Estonia Finland Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Czech republic Romania United Kingdom Slovakia Slovenia Sweden America: USA Canada Brazil South America Other: ………………………………………………………………….. Asia: Russia China India Japan Singapore Vietnam Korea Others: ………………………………. Oceania: Australia New Zealand Others: ……………………………………………. ………………………………………… Africa: Morocco Algeria Tunisia Dubai Israel Senegal Others: …………………………………………………….. Percentage of sales to export markets: ……………………. FOR R&D AND TRAINING CENTRES Is your organisation a Research Lab Technical Centre EPIC (industrial and commercial public undertaking) Training Centre Other: ………………………….
Indicate to which institutions you are attached: (e.g. INSA, UCBL, etc.) Unit:………………………………………………………………… Unit:………………………………………………………………… Unit:………………………………………………………………..
Address:……………………………………………………………………………………………………Postcode/City:………………… …………………………………… Address:…………………………………………………………………………………………………… Postcode/City:………………… …………………………………… Address:…………………………………………………………………………………………………… Postcode/City:……………………………………………………. Are you affiliated to the CNRS? Yes No Are you part of a Carnot Institute? Yes No If yes, which: …………………………………………… ……………………………………………………………………………………………………………………………………………
Initial training To what levels? …………………………………………………………………………………………………………………………………………………………………………………………………….
To what levels? …………………………………………………………………………………………………………………………………………………………………………………………………….
Inter-company training Intra-company training For all: do you belong to European and/or International network involved in chemistry and the environment? Yes No If yes, which: …………………………………………………………………………………………………….............. ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. .
If yes, which: …………………………………………………………………………………………………….................................... ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………. Association governed by law of 1901 – SIRET 485 210 082 00031– APE code 9499Z Yüklə 98,59 Kb. Dostları ilə paylaş:
| ||||||||||||||||||||||||||||||||||||||||||||||||