Membership Sign Up

Company Name
Member Name
Username
Password
Title
Mailing Address
City
Province/State
Postal/ZIP Code
Country
Daytime Telephone
Member Email
Website
For Organization Level members, Organization Description  
 
Select a Membership Level

Organization Level 4 (more than 400 employees dedicated to EAP work)
Organization Level 3 (101-400 employees dedicated to EAP work)
Organization Level 2 (51-100 employees dedicated to EAP work)
Organization Level 1 (50 or fewer employees dedicated to EAP work)
Affiliate Members(individuals and organizations not providing EAP services but who work closely with EAPs or provide services to EAPs)
Individual
Student

Select a Membership Level
For Organization Level members, what is the number of employees in your organization dedicated to EAP Work?
How many COVERED LIVES in each country are served by your EAP?
Canada (numeric)
Mexico (numeric)
United States (numeric)
Other(numeric)
Total Employees
Select a credit card type
Credit card number
Credit card expiration /
Name as it appears on the card
Complete billing address for the card
City
Province/State
Postal/ZIP Code