Become a Partner

PAGE 1

Company Headquarters Information

Company Name:

Company Web Address:

Street Address:

Address continued:

City:

State:

Zip:

Phone:

( )

-

Extension:

Fax:

( )

-

PAGE 2

With your company's corporate membership, you receive one "key" representative and three "regular" representatives. These four people will all be granted access to the members-only Knowledge Center. Any other representatives receive member discounts but will not have access to the Knowledge Center. If you would like for other representatives (aside from the aforementioned four) to have access, their is a charge of $60 each.

Representatives

Key Representative

This person will be CUPA-HR's primary contact for all communication.

Name: *

Title: *

Street Address: *

Address continued:

City: *

State: *

Zip: *

Phone: *

( )

-

Extension:

Fax:

( )

-

E-mail: *

Representative #2

Name:

Title:

Street Address:

Address continued:

City:

State:

Zip:

Phone:

( )

-

Extension:

Fax:

( )

-

E-mail:

Representative #3

Name:

Title:

Street Address:

Address continued:

City:

State:

Zip:

Phone:

( )

-

Extension:

Fax:

( )

-

E-mail:

Representative #4

Name:

Title:

Street Address:

Address continued:

City:

State:

Zip:

Phone:

( )

-

Fax:

( )

-

E-mail:

PAGE 3

Additional Representatives

If you would like to add more representatives to your company's membership roster (above the allotted number of three) it is only an additional $60 per person.

Please indicate the number of additional representatives (if any) you would like to purchase

Additional Representative #1

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #2

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #3

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #4

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #5

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #6

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #7

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #8

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #9

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #10

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #11

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #12

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #13

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #14

Name:

Title:

Street Address

Address continued

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State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #15

Name:

Title:

Street Address

Address continued

City

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Zip

Telephone:

Fax:

E-mail:

Additional Representative #16

Name:

Title:

Street Address

Address continued

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Telephone:

Fax:

E-mail:

Additional Representative #17

Name:

Title:

Street Address

Address continued

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Zip

Telephone:

Fax:

E-mail:

Additional Representative #18

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #19

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

Additional Representative #20

Name:

Title:

Street Address

Address continued

City

State

Zip

Telephone:

Fax:

E-mail:

PAGE 4

Referral

How did you hear about membership with CUPA-HR? Please select one: College or University Client
E-mail from CUPA-HR
Direct Mail from CUPA-HR
CUPA-HR Web Site
Other Association (NACUBO, etc.)
CUPA-HR Staff Member
Other

You selected "Other." Please specify:

Total Dues

Total Dues$

Payment Options

Please select your payment option: *

Payment by Check

Please mail a check to:

CUPA-HR
Attn: Membership
Department 888204
Knoxville, TN 37995-8204

Membership will be activated upon receipt of dues payment.

Payment by Credit Card

If you would like to pay by credit card, you will receive an e-mail with payment information within one business day.

Comments

If you have any questions, comments or special instructions, please describe them here.