Practitioner Membership Application

Soul Body Membership Application

Contact Information

Practitioner First Name *

Practitioner Last Name *

Business Name or DBA

Website

Email Address *

Personal Phone Number *

Work Phone Number

Address Line 1 *

Address Line 2

City *

State *

ZIP Code *

Membership Options

What is your certification or licensure? *

We ask for a current copy of these documents at the time of signing a contract.

How many years have you been in practice? *

What do you envision for your business in Ojai? How many hours do you intend to work at Soul Body Ojai? *

How many clients do you currently work with each month? *

How many clients would you like to be working with each month? *

What type(s) of service(s) do you offer? How much do you charge for your services? Do you offer packages? If so, please describe them. *

What does your ideal client look like? For instance, who is usually drawn to your work, and who do you love working with? Why do they usually come to you? What relief are they seeking? *

What kind of transformation, impacts, or healing do you see in clients you've worked with? *

Are you interested in being part our team for mentoring, accountability, and group marketing? (There is an additional application process for being part of this group.) *

Yes

Do you have business and professional liability insurance? *

Yes, I have the following coverage:Yes, I have the following coverage:

We ask for a copy of this insurance guaranteed to 1 million dollars at the time of signing a contract, current through the term of the contract.

I am willing to submit to a background check. *

Yes

We ask for a copy of this insurance guaranteed to 1 million dollars at the time of signing a contract, current through the term of the contract.

1. Professional Reference *

Please include name, email address, phone number and business relationship.

2. Professional Reference *

Please include name, email address, phone number and business relationship.

3. Professional Reference *

Please include name, email address, phone number and business relationship.

Personal Reference *

Please include name, email address, phone number and relationship.

If you have client testimonials, please include them here.

By electronically signing my name in this box, I certify that all of the information above is to the best of my knowledge and belief true, correct and complete. *

Type your full name

Date Signed *