This is an application for membership in our organization. If you have questions or need more information before deciding to join, call (704) 522-8011. Please provide the following information. Required fields include an asterisk (*). 2/4/2012 Your Name * Position Company Name *  Mailing Address *  Zip  *  Street Address (if different)   Zip   County *  City *  State Please Select Not Listed Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *  Website E-mail *    Phone Number *  Fax Billing Contact I understand that by providing my mailing address, email address, telephone number and fax number, I consent to receive communications sent by or on behalf of The Employers Association via regular mail, email, telephone, or fax. The Employers Association will not share my address, email, telephone, or fax with other organizations. Please provide the following information about your business: Type of business (please choose one) Please Select Business Service Construction Distribution/Warehouse Education Entertainment/Sports/Arts Government Healthcare Hospitality Manufacturing Durables Manufacturing Non-Durables Personal Service Printing/Media Communications Religious Staffing/Recruiting Technology Utilities Other *  Year Founded Total Number of Employees (full-time equivalents) *  Non-Profit   Yes No Unionized Yes No May We Announce Your Membership? To local media     In our newsletter   On our website (public area) How did you hear about The Employers Association? If someone referred your company to us, please let us know who so we can say thank you! Select the box for everyone who should receive a copy of the monthly newsletter and enter names and titles:   Position   Name Job Title Type Email for Electronic Bulletin President   Mr. Ms. Mrs. Email Paper Both   Human Resources Contact   Mr. Ms. Mrs. Email Paper Both   Training Contact   Mr. Ms. Mrs. Email Paper Both   Computer Training Contact   Mr. Ms. Mrs. Email Paper Both   Mr. Ms. Mrs. Email Paper Both   Mr. Ms. Mrs. Email Paper Both I would like more information on the following services: Affirmative Action Exit Interviews Assessments Group Insurance Services Background Checks/Pre-Employment Screening Facility Rentals Benefits Administration/Flexible Spending Accounts Harassment Prevention Compensation/Benchmark Surveys HR Audits Current Issues Breakfasts/Luncheons PHR / SPHR Study Course Employee Opinion/Customer Satisfaction Surveys Training Employee Handbooks Total Compensation Statements                                  Last revised: 10/14/2008