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Choose a Login Name (User ID) * It must be 4 or more characters in length and may only contain small letters, numbers, and the underscore '_'	check for uniqueness
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Primary Contact Name * First & Last name
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Primary Contact Title
Primary Contact Phone
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Alternative Staffing Program
Address
City
State
Zip Code
Web Address
Year Staffing Program Began
Annual Staffing Fee Revenues	$250,000 or less $250,000 to $499,000 $500,000 to $999,000 $1,000,000 to $4,999,000 $5,000,000 to 9,999,000 $10,000,000 to $14,999,000 Over $15 million
Legal Structure	For Profit Non Profit
Parent or Sponsor Organization If Any
Populations Served Check all that apply.	Ex-offenders Homeless Immigrants/Refugees Low Income / TANF Mature Workers (45+) People with Disabilities Recovering Substance Abusers Other
Other Population If other population served, please specify.
Job Placement Categories Please check all that apply	Clerical / Office Construction Health Care Hospitality (Hotel / Food Service) Industrial / Warehouse Janitorial / Property Maintenance Retail / Customer Service Transportation Other
Other Placement Category If other, please describe.
Membership Type *	Practitioner - Level 1 ($100.00) Annual staffing fee revenues are less than $250,000 or alternative staffing program is in development phase. Practitioner - Level 2 ($250.00) Annual staffing fee revenues are $250,000 to $1 million Practitioner - Level 3 ($400.00) Annual staffing fee revenues are $1 million to $5 million Practitioner - Level 4 ($500.00) Annual staffing fee revenues are over $5 million