321WELL is a registered trademark of Lifestyle Wellness Benefits Inc.

321WELL

WHERE YOUR QUALITY OF LIFE MATTERS
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First Name:
Last Name:
Title:
Phone #:
Mobile #:
Fax #:
Email:
URL/Web:
Special note: This member registration allows you, the registrant to be paid directly by Lifestyle Wellness Benefits Inc. And other groups utilizing wellness in their group program.  Your SSN/SIN or BN (Business Number) will be requested once you set up your direct deposit or merchant account.  
Legal Business Name:
State/Province:
Zip/Postal:
Phone 2 #:
Fax #:
URL/Web:
Business Address
Line 1:
Line 2:
City:
Phone #:
Email:
Business Contact Information
Administrator:
First Name:
Last Name:
Date of Birth:
Day:
Month:
Year:
Address
Line 1:
Line 2:
City:
State/Province:
Zip/Postal:
Group (Association, College, Institute)
If your are an active member of a group, please enter the name here:
Please note: If your are NOT an active member of a group, we may contact you for verification.
Designations and Disciplines
Discipline, Designation or Specialty
Insurance
If you are insured by liability insurance or Errors and Omissions Insurance, please list it here
Insurance company name:
Policy Number:
Please answer the following questions
Do you utilize your associations recommended pricing structure for clients?
Are you willing to present at lunch and learns for companies?
Acknowledgement
Referral
Please enter the name or vendor number of the person that referred you:
You are applying as a registered Lifestyle Wellness Provider for the 3-2-1 WELL cooperative benefit systems registration program operated by Lifestyle Wellness Benefits Inc.  You understand that this licence is granted as a direct result of your qualifications and adherence to the laws and recommended business practice of the province, state or territory that you operate within.  Your affiliation to an accepted group (association, college or institute) may allow for automatic qualification. If no group was specified, Lifestyle Wellness Benefits will issue the registration upon verification of credentials.
Your registration is being granted under the general provisions established by Lifestyle Wellness Benefits Inc. and the Advisory council representing Lifestyle Wellness Industry in Canada and United States of America.
Acceptance of your application will automatically enroll you in the 321WELL Concierge group which establishes the connections to the members.  You agree to operate through the 321WELL concierge group which oversees and maintains the high standards and requirements of the corporate group wellness market. Service Providers are offered opportunities for client acquisition, promotion of their specialty and volunteer corporate wellness promotions in a fair and equal capacity with all service providers.
You acknowledge that the information you provided in this application is accurate and complete.  Further, you understand that your registration is renewable each year and must be paid at the anniversary based on the recommended pricing and requirements set out by Lifestyle Wellness Benefits Inc. and the Advisory council. This registration is revocable at any time for actions that may be deemed as unfair trade practice, fraudulent, inconsistent with market standards or any action that endangers or intentionally influences the public in any manner that is unethical, illegal or unjust.  This program utilizes a reimbursement and direct pay to provider system and may charge an administration fee for transaction made with wellness dollars/ benefits, which is standard for all providers within a Province, State or Territory.  
Institution Graduated From: