Easthampton Co.Lab: Potential Member Application
Thank you for your interest in Easthampton Co.Lab. The first step in becoming a member is filling out this application. Once we receive your application, we'll be in touch to schedule a tour.
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First Name *
Last Name *
Phone *
Email *
Physical Address *
Street, City, STATE Zip Code
What membership level are you interested in? *
See pricing structure and benefits here: http://www.easthamptoncolab.org/membership/benefits-and-pricing/ 
Required
Number of Hours per Week *
How many hours per week do you need to use the space?
Required
Times of Day. *
What times of the day do you need to use the space? Select all that apply.
Required
Days of the week you need to use the space. *
Required
Date you would like to start. *
MM
/
DD
/
YYYY
What kind of work you do? *
What are you passionate about? *
Tell us a weird fact about yourself. *
We want dirt ;)
Please list two professional references we can contact. *
Please include email, phone, relationship, and number of years you've known them.
Allergies or special needs *
Please list anything we should be aware of.
Emergency contact. *
Please provide name, phone, email, and their relationship to you.
How did you hear about us?
If you were referred by a Co.Lab member, please list their name under "Other" so we can thank them.
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