Thank you for your support of PWC! Please enter your name and other information AS YOU WANT IT TO APPEAR in the PWC Directory. Please help us by using appropriate capitalization, spelling, etc. Although we will try to correct any obvious mistakes, the membership database and directory is a volunteer effort, staffed by humans, and we could undoubtedly miss a few things.

An Emerald Sponsor Membership includes registration of five PWC members. While completing this form, you will be asked for your name, and the name of the four other members, and their email addresses. If unknown, please state that, and proceed with completing your membership. Once we have received your initial registration, the other four members will be instructed to go to our "Individual Membership form and provide their contact information for the directory, selecting "Adding to Emerald Sponsor Membership" in the "Type of Membership" drop-down menu.

If, after submitting, you need to correct some information, or submit payment later, please DO NOT FILL OUT ANOTHER REGISTRATION FORM. Instead, send an email to contact@pwc.org with the corrected information, or for payments, go to the "Payments" page (link is found at the top of the screen) and submit your payment.

After completing this form, and clicking the "Submit" button, you will get a confirmation message that your information was submitted, and will be redirected to our our payments page.
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Type of Membership:
Emerald Presenting Sponsor Member

First Name (required)

Last Name (required)

Credentials (e.g. RN, MD, VRC, CDMS, etc. If none, please put "none.")

Profession/Job Title (required) (if none, please put "none.")

Company/Firm (required)

Email (required)

Website

Primary Contact Phone (required)

Phone Ext (if needed)

Fax

Mailing Address Line 1 (required)

Mailing Address Line 2 (optional)

City (required)

State (required)

Zip Code (required)

Service Category (required)

—Please choose an option—Claims AdministrationEmployer / Retro RepresentativesIME ServicesInterpretersLegal RepresentativesMedical Case ManagementSpecialty ConsultantsTreatment ProvidersVocational Services

Additional information: (It's just for you to add anything you want us to know! Or you can just skip it. Either way, we won't publish what you put in this box.)

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Other Emerald Members from your Company:
(These people will be sent emails requesting that they complete a separate membership registration form.)

EMERALD MEMBER 2:

Email for 2nd Emerald member:

EMERALD MEMBER 3:

Email for 3rd Emerald member:

EMERALD MEMBER 4:

Email for 4th Emerald member:

EMERALD MEMBER 5:

Email for 5th Emerald member:

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PAYMENT:

I will pay by (select one):
—Please choose an option—PayPal or Major Credit CardWill Mail CheckMy employer will payOther (please describe below)

If "Other" was selected, please explain below:

Spam sorter: Please answer the following question:
2 + 3=?

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