ERG Membership Application

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* 1. What is your name and RxBenefits email?

Name

Email Address

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* 2. Are you an employee of RxBenefits?

Yes

No

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* 3. Which ERG are you looking to join?

The Parent Project

RxB ABLE

Black Advocates & Allies

Pa'lante Unidos

P.R.I.S.M. United

Women's Initiative Network

S.E.R.V.E. - Service Members, Enlisted, Reservists, Veterans Empowerment

Other (please specify)

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* 4. Why are you interested in the selected ERG?

I am interested in joining because I am a member of the represented demographic.

I am interested in joining because I am an ally of the represented demographic.

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* 5. What are your goals for joining the selected ERG?

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* 6. By submitting my application to join, I am acknowledging that I am aware of the responsibilities, time commitments, and expectations associated with membership within the ERG. I understand that my information will be shared with the ERG leadership and published on the ERGs membership list.

Agree

Disagree

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* 7. Please provide your shirt size. All sizes are Unisex.

X-Small

Small

Medium

Large

X-Large

XX-Large