Application - Digital Therapeutics Alliance

Name of Organization*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website*

Phone

Type of Organization*

Digital Therapeutics Company
Patient Group
Healthcare System
Academic Institution
Contract Research Organization
Professional Member Association
Pharmaceutical or Biotechnology Manufacturer
Medical Technology Company
Other

If other, please describe:

Annual global revenue (if required - see below for details):

This is used to assess annual dues for organizations that include: pharmaceutical and biotechnology manufacturers, medical technology companies, device or diagnostics companies, and technology companies.

DTA Engagement

DTA’s mission is to broaden the understanding, adoption, and integration of clinically-validated digital therapeutics into mainstream healthcare through education, advocacy, and research.

In line with DTA’s mission, companies engaged in the development, support, and utilization of digital therapeutics must be actively committed to the following core principles for all DTx products. Please indicate your organization’s support of:

Membership Invoice Contact

Primary individual responsible for receiving and processing membership invoices.

Name*

First Last

Title

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone

Application Submission

In submitting this membership application, the applicant agrees to the following:*

Applicant acknowledges support of DTA’s mission and goals.
Applicant agrees to pay annual dues as determined by the DTA Board of Directors and comply with the provisions of the DTA Bylaws and Membership Agreement (available upon request).
Applicant certifies that the information in this application is true and correct.

Name*

First Last

Title*

Email*

Date*

MM/DD/YYYY

Notices

DTA reserves the right to follow up with member applicants to clarify any of the information provided in this application. Once approved, members must sign a membership agreement, inclusive of the code of conduct, and make payment of applicable dues before membership becomes official. DTA reserves the right to deny or revoke membership if it learns that an applicant or member is engaged in any conduct deemed harmful to patients or the DTx industry. DTA reserves the right to not approve an organization’s application if any of the above criteria are found to be misrepresented or revoke membership for any company that later fails to meet the necessary criteria.

Membership Application

DTA Engagement

Membership Invoice Contact

Application Submission

Notices