VAIS SETUP FORM

Please complete the form fields below

All fields marked with * are required.

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? *

Desired VAIS / Affiliate Code *

Discount to end customer *

Additional Pricing or Integration Notes

Desired Launch Date *

Copy of signed Agreement

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