Innovation Technology Association Form – Official Innovation & Technology Association

Membership Application Form

SECTION 1: PERSONAL DETAILS

Full Legal Name

Email Address

Website / Portfolio (optional)

Date of Birth

Gender

Nationality

Country of Residence

Residential Address

City / State / Province

SECTION 2: PROFESSIONAL PROFILE

Current Job Title

Organization / Employer Name

Organization Website

Industry Category

Years of Professional Experience in Tech/Innovation

Highest Academic Degree

Key Areas of Specialization

Enter your Category

Professional Affiliations / Memberships

Notable Recognitions / Awards / Fellowships (optional)

Membership Type (Choose one)

Individual Member – Executive, Expert, or Innovator

Institutional Member – Organization, Department, or Agency

Honorary Member – Distinguished Contributor (Nominated)

SECTION 3: SUBMISSION MATERIALS

Provide Links to 1–3 Public Works (e.g. articles, talks, case studies, whitepapers)

Upload Statement of Intent (800–1000 words: Describe your alignment with ITA’s mission, what you aim to contribute, and how membership will support your professional growth.)

SECTION 4: COUNCIL INTEREST & ENGAGEMENT

Which Council(s) do you wish to be considered for? (Check all that apply)

Innovation & Emerging Technologies

Cybersecurity & Data Protection

Fintech & Digital Economy

Digital Policy & Regulation

Public Sector & Smart Governance

Research, Ethics & Standards

Startups & Innovation Leadership

Diversity, Inclusion & Digital Literacy

International Partnerships & Global Affairs

2. Describe your capacity to contribute to your chosen Council(s) (Max 300 words per council selected)

Are you willing to serve on committees or participate in expert panels?

Yes

Maybe / Depending on schedule

SECTION 5: ETHICAL & LEGAL DECLARATIONS

Have you ever been convicted of a professional, criminal, or ethical offense?

Yes (please explain below)

explain below

Do you have any pending legal or disciplinary actions?

Yes (please explain below)

explain below

Disclose any conflicts of interest or affiliations relevant to tech governance or policy.

Do you agree to uphold ITA’s Constitution, values, and code of ethics?

Yes

Do you consent to periodic review and vetting by the ITA Ethics & Membership Committee?

Yes

SECTION 6: COMMUNICATION PREFERENCES

Would you be open to mentoring junior members or speaking at ITA events?

Yes

Maybe

SECTION 7: FINAL DECLARATION & SIGNATURE

I hereby declare that the information provided is accurate to the best of my knowledge. I understand that submission does not guarantee acceptance and that all applications are subject to vetting by the Membership and Ethics Committee. I accept ITA’s terms of engagement, privacy policy, and community guidelines.

Digital Signature
Full Name
Date of Submission

Checkbox Field

I agree to the above statement and wish to submit my application.