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Premium Listing (Membership)
Individual/family Membership
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Listing Form
Date: May 20th, 2012
Personal/Business Information
Email (for login)
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Password
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Confirm Password
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Organization/Business Name
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Category where your listing will appear
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Wellness Professional
Professional Services
Retail
Agriculture/Food Products
Construction/Contracting
Business Services
Nonprofit Organizations
Person Completing Form
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Title
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Mr
Mrs
Ms
Master
Dr
Rev
Firstname
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Lastname
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Contact Person
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Copy From Above
Title
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Mr
Mrs
Ms
Master
Dr
Rev
Firstname
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Lastname
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Mailing Address
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Address Line 1
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Address Line 2
Address Line 3
City
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State
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Alaska
Alabama
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Africa
Armed Forces Americas (except Canada)
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
Zip Code
*
:
Physical Address:
Copy From Above
Address Line 1:
Address Line 2:
Address Line 3:
City:
State:
Alaska
Alabama
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Africa
Armed Forces Americas (except Canada)
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
Zip Code:
Business Phone (local)
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Business Phone (Other - Toll free)
Fax
Business Email
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Website:
Other Business Affiliations (eg: BBB-Better Business Bureau, Co-Op America):
How did you hear about us?
Newspaper Ad
Article
Media
Friend
FoCuS
Word of Mouth
Website
Other:
What sustainability topics are you most interested in? (Check as many as appropriate)
Energy Conservation
Waste Prevention
Water Conservation
Green Building
Pollution Prevention
Other
1. Profit (Economy)
Date Business started
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Name your company's product(s) and/or service(s)
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What is your company's ownership structure (check all that apply)
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:
Publicly-held
Privately owned (owner/operator)
Fully-owned subsidiary
Partially-owned subsidiary
A division of a larger company
Union workplace (local)
Cooperative
Non-profit
Worker-owned
Multi-level marketing company
Other (please specify)
What are you currently doing to implement sustainable practices in your business?
What are you planning to do to implement sustainable practices in your business?
2. People (community)
Number of Employees or volunteers (including yourself)
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Full-time
Part-time
Independent Contractors
Policies and benefits that apply to all of your employees
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Equal Opportunity Employer
Flexible Schedules / Job Sharing
Flexible Spending or health savings accounts
Health Insurance Offered by business
Dental Insurance Offered by business
Vision Insurance Offered by business
Wellness/Fitness Program
Paid Vacation
Days Of Vacation
Paid Sickleave
Retirement Program
Other (please specify)
Wages and Wage Structure:
Ratio between lowest and highest paid employee (including salaried employees/owner:
Lowest Wage
:
Highest Wage
Describe how workers in your company have a voice in the company's operations and policies:
Staff Meetings
Suggestion Box
Scheduled Performance reviews
Other
Community
Your business contributes financially to community organizations
Name(s):
Your business contributes time to community organizations / events:
Name(s):
In-kind Contributions
Provide work time for staff to volunteer
Offer office space as gathering spot
Other (describe)
3. Planet (Ecology)
Use re-usable dishware
Recycle all bottles, cans, glass, and paper
Use compostable containers for take-out/leftovers
Require reusable cloth bags for purchases or offer compostable bag
Use recycled paper in office
Use recycled paper in restrooms and breakrooms
Use recycled paper with soy inks for marketing
Use or purchase renewable energy for office
Use web hosting utilizing renewable energy
Offer carbon-neutral shipping for products
Purchase carbon offsets
For
Office furnished using recycled materials or green and non-toxic furnishings
Do you encourage employees to rideshare, commute by bike, use public transportation
If so, how
Do you offer environmentally responsible products or services?
Please describe
Other environmental considerations you have incorporated into your business
Please enter verification code:
Permission
You have my permission to promote my company by publishing the above information in the GPN (Green Profitability Network) directory, when published. Your submitting this application indicates that you have read and agreed to the FoCuS/GPN
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