APPLICATION FORM

Whether you want to build awareness for your business or non-profit, increase your personal income or improve your organization's bottom line - Healthibod has a solution to fit your needs.

To apply as a Preferred Partner, Affiliated Independent Advocate, Insurers, Employers, or Non-Profit, please complete the application form below.

Name of Business or Professional Entity:

What type of Partnership are you applying for?

Contact Name:

Business or Professional Entity Web Address:

Physical Address:

Phone:

Email Address:

Is this a Qualified Charitable Organization?

If this is a Qualified Charitable Organization please provide your EIN number.

Tell us your goals and any other information that can help us serve you better:

* required field

Please complete the item(s) outlined in red.