Membership Application Form  
 
You have been invited to join our network on a six-month free trial basis.

We request that you fill-in and complete the applicantion blank to the best of your ability.

 ALL FIELDS MUST BE COMPLETED IN ORDER FOR APPlICATION TO BE PROCESSED.
Applicant's First Name: 
Last Name: 
Title:
Company Name:
Street Address:
City:
Province or Territory:
Zip Code:
Email Address:
Web Site Address:
Business Phone:
Fax Phone:
Toll Free:
What is your firm's total number of offices including your headquarters office:
How many recruiters and support personal  / project managers / researchers) are in your  company?
Is your company a member of any other  associations and if so which one(s)?
How many of your staff do wish to have listed on our site and receive our mailings?
Best Time To Contact You:
What is your desk Specialty? For example: Medical, Medical Devise, etc: Sales, Sales Support,  Management and Marketing
Please let us know why you wish to join  our network - please let us know  what you expect to gain from membership


For the Newsletter: Birth Date - Month and Day:
For the Newsletter: Wedding Anniversary:
For the Newsletter: Date & Year you became a recruiter:
For the Newsletter: Date & Year - Business Anniversary:
Are you a CPC Certified - Yes or No
Please provides us the names, telephone numbers and email addresses of two recruiters (non-members) you have recently conducted splits with:

We will be calling your referecnes prior to the final approval as a member of The US Recruiters Network.
Recruiter Number One: Name & Email Address
Recruiter Number Two: Name & Email Address
 In the event a financial dispute involving a split with a member, I agree to resolve the dispute by bringing my case to the USRN Arbitration Board.
Yes     No

Electronic Signature (Your Full Name)
Todays Date: