Form

Note: If your business needs an invoice for membership enrollment, please fill out the form below and an automated email with invoice information will be sent to you after submission of this form.

Membership Type:*

New / Renewal Vendor ($250) ($375) after July 1, 2013

Company Name:*

Address:*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Website Address:*

Number of Employees in Central Ohio Area:*

Representative Details

Primary Representative:*

Job Title:*

E-mail:*

Phone Number:*

Ext:

Fax:

Alternate Representative:*

Job Title:*

E-mail:*

Phone Number:*

Ext:

Fax:

Number of Cards Requested:*

How do you want your business name listed?*

Who referred you (Name and Company)?

Describe what product(s) and/or service(s) will be discounted, and what the percentage or amount of discount will be? Please be specific.*

How will employees obtain your discounts? (coupons, code, COESRA membership card, etc.)*

Is your company a member of the Columbus Chamber of Commerce?

Yes No

Is your company a member of the Better Business Bureau?

Yes No

What other discount program(s) are you a member of or do you participate in? (Please include any programs that you offer to other companies.)

List two business references: (Company, Contact Person, Phone)

PLEASE READ!
FAILURE TO FOLLOWING INSTRUCTIONS BELOW WILL DELAY YOUR MEMBERSHIP

You must submit a copy of your flier (preferably in PDF format), coupon or
website for approval, at the time of application. The flier must prominently state or
show the phrase "COESRA DISCOUNT", state the percentage or type of discount, and
be no larger than 4 mb in size. Make your flier attractive, descriptive and interesting to
the reader. Please give a full description of your product and/or service. Be specific
about any limitations on the discount. Colors & graphics should be appropriate for
making copies within companies and/or printing from the internet. After your approval by
the COESRA Board, you will be asked to email a final copy of your approved flier to
vendors@coesra.org. The file will only be posted on the website if 4 mb or less in size.
As part of your membership fee, the flier will be posted on the COESRA website, as
soon as possible.

Please upload flyer or coupon.*

Vendor Membership Terms & Conditions

As a Vendor Member, you agree to offer all COESRA members a general discount off your normal retail price or your best advertised price offered to the general public, or a specific product/service discount, whichever offers the greater savings. The discount must be the best or equal offering for the year to any program or group, excluding any special time limited sale. If the above discount(s) is not possible, you must submit your proposed discount to the COESRA Board, by contacting the office at (614) 830-0265, by FAX at (614) 388-5753, or by e-mail to vendors@coesra.org. Discount pricing cannot be changed during the membership year unless approved by the COESRA Board. Vendors must be active COESRA members in order to participate in any COESRA sponsored events such as Vendor Fairs, Employee Discount Fairs (EDFs) and Trade Shows. Furthermore, Vendors agree to abide by COESRA Code of Conduct. Should Vendors choose not to renew membership, Vendor agrees not to solicit any COESRA General, Community or other Vendor members under the COESRA name without the written consent of the Board. This includes phone contact, mailings, or electronic communications.

By typing your name below, you agree to these terms and conditisons.

Name:*

Date/Time:*

/ Month / Day Year

at

: Hour Minutes

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 info@coesra.org .

Payment Method:*

Credit Card Online Check by Mail

NOTE: Please allow additional processing time for all payments by check.

For security purposes, please type the phrase shown to the right.*