Online Membership Enrollment

Please use the printable enrollment form for fax or postal mail submittal. Thank You.

REFERRED BY
YES, start my membership today!

 

COMPANY NAME
ADDRESS
CITY
,WI   
ZIP CODE
NUMBER OF EMPLOYEES
TYPE OF BUSINESS

 

THE FOLLOWING DELEGATE WILL REPRESENT OUR COMPANY:
NAME
TITLE
PHONE
FAX

EMAIL

PAYMENT OPTIONS: 
Check or Money Order Enclosed
Please Bill Me (Net 15 Days)
Company Purchase Order
Using PO#
Payment by Credit Card
Note: We'll call you for card number and expiration date.

 

ORDERING OPTIONS:
Corporate Membership  $495
Associate Membership  $365

Total Payment :$

  

 

MULTIPLE DELEGATES?
NO PROBLEM!

Take advantage of great savings when you add up to 3 additional delegates at $70 each!
Annual Membership = $
Additional Delegates $ 70 x = $
Total Annual Membership = $

 

The Wellness Council is a non-profit 501(c)(3) corporation FEIN 39-1576782.

Form Updated 09/15/2006