A Holistic Healing Association
576 Valley Road #276, Wayne NJ 07470 USA | 1-888-80-4WELL
Vickie T Eaton, Executive Director | Info@CompWellness.biz
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May 1, 2004 - Please Email, or Printout and Mail
See Membership Section on the benefits of becoming a Member.
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): ____________________________________________________________
Insurances Accepted: __________________________________________________________________
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.biz/eGuide/index.htm#TOC):*
Other Modalities (see list/description at www.CompWellness.biz/eGuide/index.htm#TOC):*
Promotional Statement for Upgraded Website Listing
(Powerful statement about the Benefits of your business):*
Payment (in US dollars)
[ ] Primary Care Member – Practitioners with Doctorates and their Groups, Centers or Clinics – $1,456 (equivalent to $3.99 per day, paid annually)
[ ] Professional Member – Practitioners, Product Suppliers, Special Services or Facilities – $469 ($1.28 per day, paid annually)
[ ] Limited Member – Practitioners, Product Suppliers, Special Services or Facilities - 50% surcharge on many services – $288 ($.79 per day, paid annually)
[ ] Basic Member – Practitioners, Product Suppliers, Special Services or Facilities - 100% surcharge on many services – $192 ($.53 per day, paid annually)
[ ] Supporting Member (no listings, 166% surcharge on services) – $48
[ ] Additional one-year Membership - add 60%: $________
[ ] $48 Discount for Associate Association Members on Professional Memberships (check yours):
[ ]ABMP [ ]ACW [ ]AMMA [ ]ARC [ ]CAMA [ ]CAP [ ]CMN [ ]HANG: ($________)
[ ] Upgrade Listing - ________ extra words over 10 @ $6 per word: $________
[ ] Upgrade Listing - ________ highlighted: $24
[ ] Upgrade Listing - ________ add logo: $99
[ ] Additional Consultation –_____ hours, minimum 30 minutes: $______
[ ] Additional Services (See Marketing Materials and Services): $________
TOTAL: $_________
Non-Profit 501(c) Organizations - 65% of 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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