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 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.