Imagination Club

IMAGINATION CLUB

Please complete the application below and hit “submit” if using a credit card. If you prefer to send a check, print a copy of the completed application and mail it to: Imagination @ Work 116 19th Avenue North #401 Jacksonville Beach, FL 32250
Practice Name
Email*
example@example.com
Website
Doctor(s) Name*

PrefixFirst NameLast Name
Doctor's E-mail*
This is the email that your patient contest information will be emailed to every 6 weeks.
Office Marketing Contact
Marketing Contact Email
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
List up to 10 cities in your competitive area that you would like exclusive rights to use the Imagination Club external marketing materials. Make a circumference around your practice location(s):
Which personality best describes your practice?

Fun and upbeatProfessional yet livelyProfessional and peaceful
IMPORTANT DETAILS ABOUT YOUR MEMBERSHIP:
- Be sure to add sheliaparenton@gmail.com to your email contact list.
- Club membership is for one year. You will receive a renewal opportunity at the end of your membership year.
  
  Payment Information: To assure your financial safety, please phone Shelia Parenton with your credit card details at 904-372-0028 or 205-422-6941 after you submit this application. Thank you.
YES! I would like a one-year membership in the Imagination Club for $1500 using this payment option:

Payment in full receiving a 5% discount, reducing annual fee to $1425Four quarterly payments of $375 (must provide a credit card for quarterly payments).
Should be Empty:

IMAGINATION CLUB