Name *

First Name

Last Name

Phone *

(###)

###

####

Employee Type *

Select an option below

Exempt: Salaried Employee

Non-Exempt: Hourly Employee

Date of Birth

MM

DD

YYYY

Orientation Date *

MM

DD

YYYY

I want to join Texins automatically after my complimentary membership. *

Select an option below

Yes: Individual Membership $25/month +tax

Yes: Family Membership $35/month +tax

No

How did you hear about Texins? *

Orientation

Co-worker

Postcard

Texins Communications