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COESRA Membership
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Membership
COESRA Membership
Membership Type
*
General Membership - $150
Vendor Membership - $250
Individual Membership - $25
Community Service Membership - $50
Company Name
*
Address
*
Street Address
Address Line 2
City
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
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Website Address
*
Total Number of Employees
*
Please enter a number from
0
to
500000
.
Representative Details
Name
*
First
Last
Position Title
E-mail
*
Phone Number
*
Cell Number
Additional Representative (Optional)
Name
First
Last
Position Title
E-mail
Phone Number
Cell Number
Business Information + Referral
Date Business Began
*
(Must have been in business for one (1) year and hold a valid business license)
Two local Business References
*
(companies that are currently utilizing your services or buying your products - please provide name and phone)
Nature of Your Business
*
Type of Business
*
Manufacturing
Service
Retail
Non-Profit
Academic
Government
Other (describe above)
By what means do you distribute information to your employees
Bulletin Boards
E-mail
Company Newsletter
Company Intranet
Internal TVs
Other
How did you hear about us? If via business referral, please provide.
*
Discount Programs
What special discount program would your company provide for chapter members?
*
Is a similar discount extended to companies other than ESMSNV members? If yes, please specify.
IMPORTANT:
Vendor memberships are tentatively approved but
not finalized until the Board has reviewed and approved the business and discount program
.
Please Note
: The Board reserves the right to limit the number of Vendor members in some of the same or similar industries, i.e. Employment Agencies, Real Estate Agencies, Financial Planners, Insurance Agencies, and others as determined by the Board in order to preserve the value of the memberships.
Payment Method
You will have the option to pay online or mail your payment upon submission of this form. For your records, a copy of this form will be sent to the email address indicated above. Please direct any questions to
coesra@emralife.org
.
Payment Method
*
Credit Card Online
Check by Mail
General Membership
Price:
$150.00
Vendor Membership
Price:
$250.00
Individual Membership
Price:
$25.00
Community Service Membership
Price:
$50.00
Your Membership Key
COESRA reserves the right to approve or deny any membership application or renewal. All memberships are for a rolling 12-month period.
Disclaimer: Participation is strictly voluntary and participants assume all risks of participating in meetings, programs, activities or events. Participants will be required to sign COESRA’s Accident Waiver and Release of Liability form at all functions. COESRA is not responsible for employee services/discount programs, and member companies and their employees assume all risks when accessing these programs.
COESRA is a non-profit association of leading business, industry and government organizations dedicated to the advancement of employee services management programs which are an integral part of sound business management.