Arizona Integrative Wellness Coalition

Member ID

Primary Contact Person First name

Primary Contact Person Last name

Name of Organization or Business

e-Mail (use this email to register for events)

Phone

Website

Blog Address

Other email

Other Phone

Fax

Business Street Address

Business City

Business State

Business Postal Code

Business Location

Do you have a home-based business?

Yes

No

Do you wish to have this business address listed in the directory?

Yes

No

Mailing Address

Mailing Address City

Mailing Address State

Mailing Address Postal Code

Facebook

Twitter

Holistic Tucson Online

Please provide a brief description of your business (limit 75 words):

Directory listing text

Please list up to 3 additional individuals who can represent your company at Coalition events:

Please list up to 7 additional individuals who can represent your company at Coalition events:

How did you hear about Arizona Integrative Wellness Coalition?

Internet

Referral

Whom can we thank for referring you to the Coalition? (Include first & last name or business name.)

Are you interested in finding out about getting involved in AIWC committees or leadership roles?

Yes

No

Please select your member-to-member offer or create your own in the box below:

10% off all services

1st Visit Free

Take dollars off 1st appointment (put amount in box below)

Take percent off 1st appointment (put amount in box below)

Other offering (add in the box below)

Not offering a savings for AIWC members at this time.

Write any special member offerings here:

I agree to the code of conduct

Checked

Unchecked

Member Directory