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		Application
		Members Only Section

New Member Application

Today's Date:

First Name:

Last Name:

Title:

Company Name:

Address:

Address 2:

City:

County:

State:

Zip + 4:

Phone:

Fax:

E-mail Address:

Home Address

Home Address:

Shipping Address 2:

Home City:

Home State:

Home Zip + 4:

Working number of years in:
Benefits Compensation HRIS HR

What is your current primary functional responsibility/specialty?

If other, please specify:

What is your current level of responsibility?

What best describes the nature of your job?

How did you hear about PEBA?

If other, please specify:

About Your Organization

Type of business:

If other, please specify:

Number of employees in the U.S.:

Number of employees worldwide:

Revenue/Sales in millions of dollars:

Membership Categories

The annual billing for all members from your company will be addressed to the primary member.

Service Provider (Organizations providing products and services to plan sponsors, e.g. consulting firms, insurance companies, investment managers, tpa's, law firms)	$300
Company benefits, compensation and HR staff	$200
Nonprofit - must have less then 200 fulltime employees	$150
Additional Members from company (any category) Email Address:	$90
Interim Members (Members that are not currently employed) 1 year time limit	$25
Student Membership - Must be a fulltime student not currently employed in HR	$25

Method of payment

Credit Card Type:

Credit card number:

Credit card expiration date:

Name as it appears on card:

I authorize PEBA to charge my credit card for the above amount.