Company Name	Type of Business	Year Established
Physical Address	Contact Person	Title
City State Zip
Mailing Address
City State Zip
Through	to
Business Days	Business Hours
Shifts (if applicable)
( )	( )
Phone Number	Fax Number
Contact E-Mail Address
Number of Full Time Employees	Number of Part Time Employees

Does your company currently offer credit union membership as an employee benefit?
Yes No
If yes, name of credit union:

Do you offer Direct Deposit?
Yes No

Do you offer an employee benefits day at which we might participate?
Yes No
Dates:

Do you publish an employee newsletter?
Yes No

May we insert promotional or educational articles or ads?
Yes No

May we insert information in your payroll checks?
Yes No

Do you have a bulletin board where we can place information?
Yes No
Location:

Are you interested in having financial planning seminars at your company location for your employees?
Yes No

Are you interested in having us speak to your employees at your facility?
Yes No

Special Notes/Comments

Priority One Credit Union Representative

Date completed/filed