Imagination Facebook Club

FACEBOOK 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
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
Office Marketing Email
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
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! make my staff's job easier, sign us up for the Facebook Club today!

$175 for One-Year Membership
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FACEBOOK CLUB