Fax or mail this application to:

Imagination @ Work, LLC

116 19th Avenue North, Unit 401

Jacksonville Beach, FL  32250

Phone:  904-372-0028

FAX:  904-372-0631

 

Imagination club

APPLICATION

Practice Name:                                                                                                                  

Doctor(s) Name:                                                                                                                

                                                                                                                                              

Business Address:                                                                                                             

                                                                                                                                              

Phone:                                                                              Fax:                                            

Web Site:                                                                                                                             

Email Address:                                                                                                                  

Marketing Contact for Office:                                                                                               

· List up to 10 cities in your competitive area that you would not want Imagination @ Work

to allow membership in order for you to sign a membership contract:

                                                                                                                                                                        

                                                                                                                                                                        

                                                                                                                                                                        

                                                                                                                                                                        

                                                                                                                                                                        

· What percentage of your annual budget do you normally assign to marketing:          

    ____1-2%                       ____3-4%                           ____5+%        

 

· Approximately how many referring dentists do you have at the following levels:

            3-9 referrals per year                         10-19 referrals per year                      20+ referrals per year

 

· Which personality best describes your practice:

    ____Fun and upbeat                ____Professional yet lively             ____Professional & Peaceful

 

· Your portfolio of information will be emailed to you each quarter.  Is there a different email address than the one listed above to send this to?                                                                                                         

 

I would like to request a one-year membership in the Imagination Club.  I have read and understand the Club Guidelines and would like to request the following $1500 annual membership payment option:    

____Payment in full receiving a 10% discount, reducing annual fee to $1350.

____Quarterly credit card charges at $375 per quarter, for one full year of membership.

 

Payment Information:

o Check Enclosed                o Visa          o Mastercard

Credit Card #                                                                                                        

Expiration Date:                                               

 

                                                                                                                    

Doctor’s Signature                                                         Date