Application for a 100% FREE Multifunctional Rehabilitation Massage Chair

​

Prospective Lead – General Information

Contact Information

• Company Name: ______________________________________________

• Contact Name: _____________________________ Title: _______________

• Phone: ___________________ Cell: _________________

• Email: _____________________________

• Professional Medical License: _________________________ License #: ____________________

• Issued Date: ________________ Issued By: ___________________________________________

• Number of Locations: ________

• Wi-Fi Access? ☐ Yes ☐ No

• Website: __________________________________________

Chair Placement Details

• How many locations would you like to set up a FREE Rehab Massage Chair? ___________ (Recommended: 1 chair per 3 physical therapists. Example: 1-3 therapists = 1 chair; 4-6 therapists = 2 chairs, etc.)

• Installation Address: _______________________________________________________

• Number of Physical Therapists: ______

• Estimated Daily Patients: ______

• Average Therapy Time:

  • ☐ Less than 20 minutes

  • ☐ 21-30 minutes

  • ☐ 30-60+ minutes

Company Information

• Legal Name (as per Articles of Incorporation): _________________________________________

• DBA (if applicable): _____________________

• Contact Person Name & Title: ________________________

• Company Address: ________________________________________

  • City: _______________ State: ____ ZIP: ______

• Phone: _____________________ Fax: ________________________

• Email: _________________________

• Legal Form of Business:

  • ☐ Corporation

  • ☐ Partnership

  • ☐ Proprietorship

  • ☐ LLC

• Date Business Started: _______

• State of Incorporation/Registration: ________

• Number of Employees: ______

• Number of Locations: ______

• Average Daily Customer Traffic: ___________

• Owner’s Cell: ___________________

• Wi-Fi Available? ☐ Yes ☐ No

• Current Property Insurance Agent’s Name: ________________

  • Phone: _________________ Fax: _______________

  • Email: _____________________

Facility Information

• Door Entry Dimensions:

  • Length: _______________

  • Width: _______________

• Type of Business: ______________________________________________________

Corporate Officers / Partners / Owners

NameTitleOwnership %

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Submission Instructions

Please complete this form and submit it to info@rehabchairs.com. If you have any questions, contact us online.

Thank you for your interest in the FREE Rehab Massage Chair Program!