Provider Preliminary Application Form

Representative Details

First Name *

Last Name *

Phone *

Email *

Position / Job Title: *

Length of Employment:

Company / Organization Details

Company Name:

Industry:

Work Phone:

Website:

Company Registration No.:

Company Vat No.:

Address

Street Address

City

Postal code

Brief Description of Your Business/Services: *

Which services or products would you like to offer through the Holistic4Me Voucher Program? *

Please choose which services/products are applicable.

Option 1
Option 2
Option 3
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Additional Details

Application Motivation *

How will you promote the Holistic4Me Voucher Program to your customers and at your company locations ? *

On-site / In-store signage

Website Promotion

Social Media Promotion

Email Marketing

Whatsapp Marketing

Word of Mouth

Other:

Any Additional Comments or Questions?

Supporting Documents

Consent

Are you able to honor voucher redemptions within the terms of the program? *

Yes

Do you agree to the administrational process, payment process, fee structures of the Holistic4Me Voucher Program and voucher redemption process as outlined in the Holistic4Me Voucher Terms & Conditions? *

Yes

Do you acknowledge and understand that Holistic Embodiment uses Third-Party payment Gateways Payflex and/or MoreTyme to process payments for these vouchers? *

Yes

Do you accept the payment gateways Term's & Conditions? *

Yes

I Consent to Receive Notifications, Alerts & Product Updates & Occasional Marketing Communication from Vantex Collab t/a Holistic Embodiment. Message frequency varies. Text HELP to {{location.phone}} for assistance. You can reply STOP to unsubscribe at any time.

Signature *

Clear

Date Signed:

By submitting this form, I acknowledge that the information provided is accurate and complete to the best of my knowledge. I consent to Holistic4Me contacting me regarding my application to become a participating provider.

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