Sponsorship Application
May 1, 2004 - Please Email, or Printout and Mail

See Membership Section on the benefits of Membership.
Offered to Qualified Practitioners, Practitioner Organizations and Complementary Healthcare Businesses
in the North America and US Territories.

Please provide the following information:

Full Name, Credentials: __________________________________________________

Company Name: _______________________________________________________

Email: ______________________________________________________________

Private Email (for internal notifications): ___________________________________________________________________

Website: __________________________________________________

Business Address (include Postal Code): _____________________________________

Mailing Address (include Postal Code): ______________________________________

Phone (the only one published): _______________________   Fax: _____________________

Mobile: _____________________   Pager: _____________________

Education (institution, graduation date, degree/certificate): ______________________________________

              ____________________________________________________________________________

Licenses (name, state, date): ____________________________________________________________

Professional Recommendation:

Member Name: _________________________________________

OR Three Professional References (no relatives or family friends, please):

Name: ________________________________   Phone: ___________________

Name: ________________________________   Phone: ___________________

Name: ________________________________   Phone: ___________________

Primary Modality (see list/description at www.CompWellness.org/eGuide/index.htm#TOC):*


Other Modalities (see list/description at www.CompWellness.org/eGuide/index.htm#TOC):*


Promotional Statement for Upgraded Website Listing
(Powerful statement about the Benefits of your business):*


Payment (in US dollars)

[   ]  Corporate Sponsor/Member – Businesses of 10 or more, Groups, Centers or Clinics - 3-line Sponsorship recognition with Logo on literature and website - boxed listing with 60-word description – $849

[   ]  Professional Sponsor/Member – Businesses, Practitioners, Product Suppliers, Special Services or Facilities - 3-line Sponsorship recognition on literature and in Resources section of website - boxed listing with 30-word description – $699

[   ]  Limited Sponsor/Member – Businesses, Practitioners, Product Suppliers, Special Services or Facilities - 1-line Sponsorship recognition on literature and bolded Member listing with 10-word description - 50% surcharge on many services – $449

[   ]  Basic Sponsor/Member – Businesses, Practitioners, Product Suppliers, Special Services or Facilities - 1-line Sponsorship recognition on literature and non-bolded Member listing with 10-word description - 100% surcharge on many services – $299

[   ]  Non-Profit 501(c) Organizations - 35% discount on above Sponsorships: ($________)

[   ]  Supporting Sponsor/Member (2-line listing, 166% surcharge on services) – $100  

[   ]  Bold printed Listing plus 10 extra words: $60

[   ]  _______ Additional Description Words @ $6 each: $________

[   ]  Additional one-year Sponsorship - add 60%: $________

[   ]  Additional Consultation –_____ hours, minimum 30 minutes: $______

[   ]  Additional Services (See Marketing Materials and Services): $________

[   ]  Advertising (See Denver CompWellness journal Directory Ad Rate Card - includes Sponsorship): $________

TOTAL:               $_________

Optional Payments for a TOTAL more than $600 (on credit cards only, no debit card or invoicing):   $_________

[  ]  monthly(15%)   [  ] bi-monthly(28%)   [  ] quarterly(39%)   [  ] 4-monthly(50%)   [  ] half year(69%)

Payment method:   [ ] Check*   [ ] Money Order*   [ ] Credit Card (AMEX only):

CC # _____________________________________ Exp Date ________

Signature _________________________________________________

Emailing Credit Card Information: For Internet email security, it is a good idea to send your card number in two parts.
Simply prepare your email with part of the number, send it, then immediately send the rest of the number.

*By check or money order – send to:
CompWellness Network, 576 Valley Road #276, Wayne NY 07470 USA


Latest List of Member Benefits



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