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:*

General Membership - $250
Company Name:*

Address:*

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:*
Company Involvement in Employee Services
Group or department responsible for employee services (HR, E-Club, Benefits, PR, etc.):*
Is employee services part of your job responsibilities OR do you volunteer to manage employee services?*
Contacting You

What is your preferred method and the best time for an Associate (Vendor) member representative to
contact you?
Preferred Method of Communication:
Time of Day:
How Do You Promote Associate (Vendor) Member Offerings at Your Facility?

Bulletin Board Email Intranet Posters Payroll Stuffers Newsletter Flyers Other
If specified "other" above, please describe:
Do you distribute coupons?

Yes No
Do you have an employee store?

Yes No
Other Information:
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.*
Should be Empty: