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VAIS SETUP FORM
VAIS SETUP FORM
Please complete the form fields below
All fields marked with
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Complete this form to get started:
Organization
*
Company Name / Website URL
*
Assigned Sales Contact (Internal)
*
Main Partner Contact Name
*
Main Partner Contact Phone Number
*
City
State
Main Partner Contact E-Mail Address
*
Landing Page Required?
*
- Select an option -
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Desired VAIS / Affiliate Code
*
Discount to end customer
*
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Free Shipping
Additional Pricing or Integration Notes
Desired Launch Date
*
Which one best describes you?
Arranging meal delivery for a member or patient
I work with or for a Healthcare Organization
I work with or for an AAA or State Agency
I'm a Case Manager
Arranging meal delivery for myself
I'm an Individual or Caregiver
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