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Note - Fields marked with a * are required.
Company Name*
Address 1*
Address 2
City*
State*
Zip*
Phone*
Fax
Website
Referred By
We hereby apply for membership in the HIA-LI:*
(Includes a subscription to the Hauppauge Reporter)
$400 Regular Membership
$475 (companies 200+ employees)
$200 Not-For-Profit Membership
$100 Talent Transition Membership*
$100 Get In The Game Membership**(Member of the millennial generation (18-28) and seeking employment)
I am including a donation to the HIA-LI Scholarship Fund:
($25 suggested donation)
Company contact person for HIA-LI use and for Membership Directory listing
First Name*
Last Name*
Title*
Email*
Brief description of company*
President's Name*
Human Resource Director
Manufacturing Manager
Company Type*:
Manufacturer
Distributor
Service Provider
Number of employees:
Do you ship goods to other countries?*
YesNo
Do you bring goods in from other countries?*
Yes
No
Please send the Hauppauge Reporter to (Other than contact person. Name & Title):
Name:
Title:
Name:
Title:
METHOD OF PAYMENT*
Membership & Scholarship Fund Donation
Total Amount:
($ Membership /
Scholarship)
Visa
Master Card
American Express
Paying by check
Card Holder's Name*
Credit Card Number*
Expiration Date*
mm/yy
NOTE: If sending payment by check, please complete, print this form and mail to the address below. All applicants subject to the approval of the Board of HIA-LI. Your welcome kit will follow HIA-LI's receipt of your application and dues.
* You must be currently unemployed and actively job seeking to qualify for this membership. Consultants must join as a company membership.
** If you are a member of the millennial generation (18-28) and seeking employment
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