Company Information

    Company Name:

    Primary Company Business:

    Company Address:

    City:

    State:

    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:

    City:

    State:

    Zip:

    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: