A Professional Association
Post Office Box 678, Littleton CO 80160-0678 | 1-888-7-HELP-24
Kenton Johnson, Executive Director | Info@CompWellness.net
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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.net/eGuide/index.htm#TOC):*
Other Modalities (see list/description at www.CompWellness.net/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, Post Office Box 678, Littleton CO 80160-0678 USA
Latest List of Member Benefits
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