Name of Service Provider/Business *
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Year Established *
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Address 1 *
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Address 2
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City *
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State * and Zip Code *
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Mailing Address (if different from above)
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City
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State and Zip Code
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Main Telephone Number *
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Secondary (Cell) Telephone Number
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Website of Service Provider/Business
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Contact Name and Title *
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E-Mail Address *
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Business Information |
Please describe/summarize the services performed and/or products provided by you or your business: *
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Is your location of service handicap accessible? *
Yes No Not Applicable |
Do you provide in-home services, i.e. haircut, medical check-up, meal prep, etc.? *
Yes No Not Applicable
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Do you provide home delivery service, i.e groceries, meals prescriptions, etc.? *
Yes No Not Applicable |
Calls from your customers/clients are returned: *
Within the Hour Same Day
Next Day
Other |
Geographic area you serve: *
Newport Portsmouth Jamestown Middletown Tiverton Little Compton
All Newport County Beyond Newport County |
Preferred providers are asked to provide a special service or discount that is marketed specifically to Living Well in Newport members, i.e. 10%-20% discounted services, free equipment installation, etc. These discounts are important to our members and assist in creating regular clientele with our Preferred Providers.
Please describe/summarize the special service or discount you or your business will provide all members of Living Well in Newport. *
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Bonded
by whom |
Insured
by whom |
Licensed
by whom
Proof of insurance and license may be required. You will be contacted if this information is needed. |
Client References:
In order to become a Preferred Provider for Living Well in Newport you must provide three client/customer references. |
Client/Customer Reference *
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Address *
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Phone *
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Email *
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Client/Customer Reference *
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Address *
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Phone *
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Email *
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Client/Customer Reference *
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Address *
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Phone *
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Email *
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Vendor/Credit References:
In order to become a Preferred Provider for Living Well in Newport you must provide three three vendor/credit references. |
Vendor/Credit Reference *
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Address *
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Phone *
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Email *
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Vendor/Credit Reference *
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Address *
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Phone *
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Email *
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Vendor/Credit Reference *
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Address *
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Phone *
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Email *
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*
By checking this box I am certifying that the information I have provided is accurate, and hereby agree to be bound by the statements and representations that I set forth herein, including but not limited to, the discounts and/or special services that I will provide to all members of Living Well in Newport. |
Name and Title *
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Date *
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