ERC Membership Application


Organization Information
Organization Name:
Addresss:
City:	State: Zip: County:
Phone:	Extension:
Primary SIC:
Web Address:
Number of Full-Time Employees:
Is your business a non-profit?	YesNo
Federal Tax ID:
Primary Contact Information This person will receive ERC mailings; survey invitations and confidential survey results; web access to the ERC Member Center; our weekly e-newsletter, Quick Hits; email updates and invoices.
First Name:
Last Name:
Title:
Email:
Phone:	Extension:
Reasons for joining:
Payment Information Your annual ERC membership dues are based on your number of full-time equivalent employees employed at the location(s) that will access ERC member services. Membership is renewed automatically based on the date you join ERC. Dues invoices are sent 60 days prior to renewal and are payable upon receipt to ERC. An application fee of $150.00 will be added to your first year membership dues, payable with this application. For a schedule of dues, please click here. If you have a Discount Code, please enter it below and click "Validate" to apply your discount.
Discount Code:	Validate Enter discount code and click validate to apply
Annual Dues:
Card Type:
Card Holder's Name:	(As it appears on card)
Credit Card Number:	(No dashes or spaces)
Expiration Date:
Verification Code:	(3 digit code on back of card for VISA, 4 digits on front of card for AMEX)
By clicking “Join Now” you acknowledge that you have read, comprehend, and agree to comply with ERC’s guidelines for membership. Online Payments

Organization Information