FFA Focus Facility Association – Northeast Chapter Application for Membership
Your Title:	Mr. Mrs. Ms. Dr.
Your Full Name:
Company Name
Companies Primary Business Areas include: Check all that apply:
Qualitative Research Facility Use Only Quantitative Research	Recruiting Only All of the above Other
If Other, please specify:
Company Address:
City:
State:
Zip:
Telephone:
Fax:
Company e-mail:
Direct e-mail:
Representatives of Facility:  List no more than three individuals who are authorized to represent your company in all matters regarding the FFA only one person per company is allowed to vote per meeting.  All representatives are to have authority to vote.  Each representative mentioned below agrees to attend at least 25% of the FFA meetings in a fiscal year.  Each representative understands that to maintain status as a representative for the FFA his/her current job must be at least 50% focus facility based.
First Representative:
Title:	Owner Manager Other
If Other, specify:
Second Representative:
Title:	Owner Manager Other
If Other, specify:
Third Representative:
Title:	Owner Manager Other
If Other, specify:
I certify that all of the information furnished above is correct and truthful to the best of my knowledge, and that the above said persons represent the said facility in matters pertaining to its operations.
Name of President or Owner:
Title:	President Owner

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