Thank you for supporting PWC with your sponsor membership!

Please enter your name and other information AS YOU WANT IT TO APPEAR in the PWC Online Directory. Please help us by using appropriate capitalization, spelling, etc. Although we will try to correct any obvious mistakes, the membership database and directory are volunteer efforts, staffed by humans, and we will undoubtedly miss a few things.

If, after submitting, you need to correct some information, or submit payment later, please DO NOT FILL OUT ANOTHER 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 payments page.
_____________________________________________________

Type of Membership (select one):
—Please choose an option—Gold Sponsor Membership ($225)Platinum Sponsor Membership ($375)

First Name (required)

Last Name (required)

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

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

Company/Firm (required)

Please choose from the drop-down menu. If your company is not listed, please select "OTHER" and fill in your company name below. If you do business under your personal name, and do not have a company name, then please select "None."
—Please choose an option—OTHERNONEAchieve Consulting Team, IncACMMC Spanish InterpretationsApproach Management ServicesAssurance Case Management, Inc.ATI Physical TherapyCapen Industrial Rehabilitation ServicesCascade Rehabilitation Associates & Summit Rehabilitation, LLCCausey WrightCHI Franciscan HealthComp Solutions, Inc.Comprehensive Risk ManagementCoventry Workers' Comp ServicesDepartment of Labor & IndustriesEIS Group, Inc.Endres Law FirmEverHome HealthcareExamWorks IncExtreme ErgonomicsFreeborn Wellness, PLLCGenex ServicesGrant & AssociatesHarbor Health Solutions, LLCHighline Hand TherapyHM Vocational Services, LLCHolmes Weddle & BarcottIndustrial RehabKoplin Law, LLCLarry A. Lehmbecker Law FirmLaw Offices of Katherine L. MasonLaw Offices of William H. Taylor, PSMark Harrington & AssociatesMaureen Larson ConsultingMcDonald & Associates InvestigationsMedical Consulting LLCMES SolutionsNelco Rehabilitation AssociatesNorthwest Ergonomics & Assistive TechnologyNorthwest Return to WorkNTCS Vocational TestingNurseWorks NorthwestOlympic Sports & SpineOSC Vocational Systems, Inc.Pacific Rehabilitation CentersPanel of ConsultantsPatricia Santiváñez & AssociatesPayne & Associates, Inc.Peoples Injury Network Northwest (PINN)Performance Work RehabilitationPhysioHealth.ClinicPK Consulting & Case ManagementPratt, Day & Stratton, PLLCPrecisionary, Inc.Professional Claims Intervention ServicesPSA HealthcareRainier Case ManagementReck Law, PLLCReeve Law FirmRehabilitation Institute of WashingtonReid Case Management, Inc.RET Physical Therapy GroupCA Pacific Case ManagementSharpe Law FirmSolutions Northwest, Inc.Strategic Consulting Services, Inc.Sunrise Medical ConsultantsThe Walthew Law FirmVocational AlternativesVocational Rehab SpecialistsWA Workers' Comp Law, PLLCWallace, Klor, Mann, Capener & Bishop, PCWashington Self-Insurers AssociationWCS, Inc.

If "Other," please enter the name of your company (if none, please select "none" from the menu above, and leave this field blank:

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.)

_____________________________________________________

INTEREST INVENTORY:
Optional!

Program/Speaker suggestions:

I would like to help with: (check as many as apply)
Website
Event Planning
Event set up and check-in
Directory preparation and publication
Membership and Sponsorship Drives
PWC History Project

I am good with: (check as many as apply)
Computers
Finances
Mail merge
Websites
WordPress
Fund Raising
Computer graphics
Marketing
Flower arranging
Public speaking
Negotiations

Other Comments or Suggestions:

_____________________________________________________

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=?

Δ