Anchor Wellness Provider Application For those wishing to apply to the Anchor Wellness Network Today's Date - Month - Day Year Date Contact Info Provider Name * First Name Last Name Provider Email * example@example.com Is this your business email? * Yes No Provider Number * - Area Code Phone Number Is this your business number? * Yes No Home Address * Street Address Street Address Line 2 City State / Province Postal / Zip Code Have you been practicing for more than 3 years? * Yes No Legal Info Organization Name Organization EIN Organization Type * Limited Liability Corp. S-Corp. Not Filed Yet Service Type * Massage Therapist Physical Therapist Registered Dietician Health Coach Yoga Therapist Personal Trainer Pilates Instructor Medical Doctor Nurse Practitioner Have you been operating for more than 1 year? * Yes No Have you registered with your state for tax filing? * Yes No Organization Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Organization Number - Area Code Phone Number Organization Email example@example.com Website URL * ex. www.example.com or N/A Year the Organization was founded (since) e.g since 2003 Do you have a team/employees? * Yes No Number of Employees Team Details Do you use a Lawyer? * Yes No Lawyer Number - Area Code Phone Number Lawyer Email example@example.com Finance Info Do you have a business bank account? * Yes No Which bank do you work through? Bank Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Bank Number - Area Code Phone Number Accepted Payment Methods * ACH Check Credit Card Venmo PayPal Cash App Apple Pay Google pay Do you have outside funding? * Yes No What type of funding? What source of funding? Do you have bookkeeping software? * Yes No Which software(s) Do you use a CPA? * Yes No CPA Number - Area Code Phone Number CPA Email example@example.com Insurance Info Do you have malpractice/liability insurance? * Yes No Who is the provider? Please upload proof of insurance. Browse Files Cancel of Top Level Info What is your Mission? * What is your Vision? * What are your Values? * What are your Principles? Who is your Target Audience? * What is your Target Audience's Obstacle? * What is your Benefit for your Target Audience? * What makes you or your service Unique? * What is your Promise of your Benefit to mitigate/solve the Customer Obstacle? * What are your Suceessess? * How do you measure your Success? * Branding & Marketing Info Have you defined your Brand's Archetype? * Yes No Please describe your Brand Archetype. Please upload any high-res logo files. Browse Files ex. .png, .jpg Cancel of Color Palette RGB or HEX Color 1 Color 2 Color 3 Color 4 Other Typography Name Font 1 Font 2 Font 3 Other What is your referral network? * Physical Therapists Physicians Therapists Coaches/Pros Massage Therapists Chiropractors Dieticians Personal Trainers Pro Teams Collegiate Teams High School Teams Performance Groups/Teams Corporate Affiliates/Partnerships Who hosts your website? ex. wordpress, wix, etc Who hosts your DNS? ex. GoDaddy, etc Do you have Google My Business? * Yes No Google My Business URL ex. www.example.com Do you have a content strategy and calendar? * Yes No Social Media Info * Handle or URL Instagram Facebook LinkedIn Twitter TikTok Pintrest Other Do you have a blog? * Yes No Please select how you market. * FB ads IG ads Google ads LinkedIn YouTube ads Organic Content marketing Do you track your marketing/traffic analytics? * Yes No Please describe how you track your marketing/traffic analytics? ex, Google Analytics, Funnelytics, Agency Analytics, etc Do you have stock photos? * Yes No Please upload some stock photos including headshot. * Browse Files Cancel of Do you outsource any of your marketing? * Yes No Marketing Org. example@example.com Marketing Org. Number - Area Code Phone Number Marketing Org. Email example@example.com Finalize Representative Signature * Clear Date Signed * - Month - Day Year Date Please verify that you are human * Submit Print Form Should be Empty: Now create your own JotForm - It's free! Create your own JotForm Anchor Wellness Provider Application
