ERA - Request Guest Trial

Step 2: Please fill out the application form below.

(RED TEXT indicates required information)

Name

First	Init	Last	Suffix (Jr., Sr., etc.)

Business

Business Name

Address

City	State/Province	Postal/Zip
	If no State/Province in the address, select Not Applicable. (It's at the bottom of the list)	If no Zip or Postal Code in address, type NA in this box.

Country

Phone Number

( ) -

FAX Number

( ) -

Please enter a valid email address.
Email Address: Confirm Email Address:

User Name

Please enter a user name for your account. User name must be between 7 and 16 characters in length and consist of only letters and numbers. Note that user names are not case-sensitive.
User Name:	Confirm User Name:

Password

Please enter a password for your user account. Password must be between 8 and 16 characters in length and consist of only letters and numbers (no spaces or symbols).Passwords must also include at least one number, one lower-case letter and one upper-case letter.
Password:	Confirm Password:

Number of Employees

Full time	Part time
	You must enter a quantity in each box, even if it is 0

Year Business Started

Please use a four-digit year. (Example: 1978, 2001)

Company Website

Do not include "http://" (Example: www.electricalrebuilders.org, www.theeren.net)

Referred By

How did you find out about Electricalrebuilders.org?

Electrical Rebuilder's Exchange	From a supplier	Search Engine
At a seminar	From another Rebuilder	Other

Please type any comments to include with your applicaton.

Certify that information is correct

I certify that the above information is true and accurate to the best of my knowledge. I understand that the ERA reserves the right to reject applications containing fictitious and inaccurate information.