New Authorized Provider Enrollment Form

Please take a few minutes to complete the LifeGuardian Authorized Provider Enrollment Form and your order will be transmitted electronically direct to the LifeGuardian Customer Service office.

For fastest sign-up, simply complete this order form and you're order will be submitted immediately. If you prefer, click here to print out and FAX or Email your LifeGuardian Authorized Provider Registration Form.

Please Note: * Indicates required field.

1. PROVIDER INFORMATION
*Company/Legal Name:
*Primary Contact Name:
*Title/Position:
*Physical Address:
Suite or Unit #:
*City
*State:
*Zip Code:
Mailing Address:
Suite or Unit #:
*City
*State:
*Zip Code:
*Telephone Number:
 (Please Include Area Code)
FAX Number:
Web Site Address:
Email Address:
2. BUSINESS TYPE (Choose One)*
Individual Sole Proprietorship Partnership
Limited Liability Company Corporation (State):
Year Founded: # of Offices / Locations:
# of Employees: # of Clients/Patients:
3. PRIMARY INDUSTRY (Check all that apply)
Hospital Nursing Home Rehab Facility Assisted Living
Police/Fire Dept In-Home Care Pharmacy Medical Equipment
Medical Office Ambulance Paramedics Senior Community
Senior Services Nursing Home Assessment Physical Therapy
Other:
4. PLANNED DISTRIBUTION METHODS (Please check all that apply)
Retail Store Medical Office Industry Referrals Internet/Web Site
Phone Sales Direct Mail Print Ads Patient Handouts
Other:
5. UPON ACCEPTANCE, WE ARE INTERESTED IN THE FOLLOWING (Please check all that apply)
Order Forms Patient Handouts Color Brochures Brochure Stands
Web Graphics Program Stickers Affiliate Program Business Cards
5. HOW WOULD YOU LIKE TO RECEIVE YOUR COMMISSION PAYMENTS? (Select One)
Mailed Check  
Direct Deposit  
  Bank Name:
  Account#:
  Routing #:
8. AUTHORIZED PROVIDER ENROLLMENT AGREEMENT

The above is a true and accurate statement of our business affairs and is made for the sole purpose of registering for the LifeGuardian Authorized Provider Program. LifeGuardian Technologies, LLC may verify all information contained in this application. Applicant is legally authorized to enter into this Agreement and hereby acknowledges that I have read, understand and accept, without limitation or exception, the terms and conditions contained within the latest LifeGuardian Authorized Provider Program Agreement and agree to abide by all requirements as an authorized LifeGuardian medical alarm provider upon acceptance.
*Agreement Acceptance
 .
*Accepted By (Type Name):
*Date Completed:
*Phone Number:
*Email Address
How Did You Hear About Us?:
*LifeGuardian Representative: