Company Information

    Company Name:

    Primary Company Business:

    Company Address:

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    Zip:

    Company Phone:

    Ownership:

    Number of Employees:

    Years in Business:

    Company Website:

    Company Email:

    Company Bank References:

    Applicant Information

    Applicant Name:

    Applicant Position:

    Applicant Address:

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    Phone:

    Years at Company:

    Applicant Email:

    How did you hear about the Portland Executives Association?

    How would membership in the Portland Executives Association benefit you?

    How would your membership benefit the Portland Executives Association?

    PDXEX Sponsor:

    Sponsor Company Number: