Corporate Health and Welness Association MEMBERSHIP APPLICATION FORM

Coporate Health and Wellness Association (CHWA)
Please complete this form for submission to Corporate Health and Wellness Association
Mail: 1128 Royal Palm Beach Blvd, Suite 138,
Royal Palm Beach, FL 33411
Tel : 561-204-3676

Company Information

Company : *

Company Address : *

Postal Code : *

City : *

State : *

Country : *

Title / Position : *

Main Phone :*

Fax :  

Main Email : *

Verify Main Email : *

Website :  

Applicant/Member Information

First Name : *

Please enter the main point of reference/contact person that the CHWA should communicate with regarding membership.

Last Name : *

Title/Position : *

Phone : *

Email : *

Verify Email : *

Email to receive all CHWA correspondences : *

Please select the type of membership you are applying for:

Organizational Membership

	Corporate Wellness Provider Membership (2 Year Membership; includes the Certified Wellness Provider™- Excellence in Wellness*)	$2,000
	Corporate Wellness Provider Membership (1 Year Membership; includes Certified Wellness Provider™- Excellence in Wellness*)	$1,500
	Corporate Membership	$500
Please select the type of Professional Membership that best describes your organization:
	Employer Insurance Agency, or Consulting/Brokerage Firm Insurance Company/Health Plan Third Party Administrator Insurance/Healthcare Organization
	Government, University or Non-Profit Membership	$400
Professional Membership
	Individual Membership (2 Year Membership; Individual Membership includes the Certified Corporate Wellness Specialist™- Excellence in Wellness**)	$500
	Individual Membership (1 Year Membership; Individual Membership includes the Certified Corporate Wellness Specialist™- Excellence in Wellness**)	$300
	HR/Benefits Director or Wellness Manager Agent, Broker or Consultant Insurance/Healthcare Industry Professional
* Organization must apply for certification and meet the industry standards in order to receive the certification. ** Applicant must complete the online application, complete 16 hours of educational training, and complete and pass the online examination in order to receive the certification.

Terms & Conditions

By Clicking here I Agree to the Terms & Conditions applied for the Membership of the Corporate Health and Wellness Association (CHWA).

CHWA Directory

Yes, include me in the CHWA Directory and CHWA Website Listing.
No, exclude me from the CHWA Directory and CHWA Website Listing.

Verify Security Code

Type security Code : *