The Private Duty Resource Group
Membership Application

Please complete the following application to the best of your ability. If you qualify for membership in your geographical region, a member of PDRG's staff will contact you for further assistance and to establish a payment plan for your yearly dues. We look forward to working with you!

Company Name:
Owner's First Name:		Owner's Last Name:
Headquarters Address:
City:		State:	Zip:
Phone:	Fax:	Email:	Website URL:

Please respond to the following questions to the best of your ability:
1. On average, how many customers/clients do you serve in a week's time?
50-100	101-150	151-200	list

2. How many inside employees do you employee (not in the field)?
1-5	6-10	10+(please list number)

3. How many field employees do you employ per week?
50-100	101-150	151-200	list

4. What is your geographical area?

Please provide a short description of your firm (25-50 words):

When you have completed this application, please hit Submit (above) and a staff will contact you for further assistance.

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