SJ Wellness Council PO Box 1351, Marlton, NJ 08053
Salutation (Check One): Ms.___ Mr.___ Dr.___ Miss___ Mrs.___
First Name ___________________________ Last Name ____________________________
Mailing Address _____________________________________________________________
City ___________________________________ State ______ Zip Code ________________
Telephone ( ) _________________________ (Circle) Home Cell Work
Email address ________________________________________________________________
Website ____________________________________________________________________
Membership type applying for: Individual Practitioner _____ Holistic Business_______
If Business, business name for listing ______________________________________________
Note: One business/person per one membership. If your holistic business or practice has multiple
practitioners, other individual practitioners in your holistic business or practice would need to buy their
own SJ Wellness Council memberships to have their own information posted. See Benefits of Membership.
Holistic practice(s)/Field(s): 1. ___________________________________________
2. ___________________________________________
I heard about SJ Wellness Council through:
SJWC website ____ SJWC Member ____ Ad/Article ____ Other ____
Member/Website/Publication/Other details: ____________________________________
I would like to serve on a committee as a supporting member: Yes ____ Maybe _____ No _____
Check payable to SJ Wellness Council is enclosed (mailing in) _____
I am paying online ______Make payment online at PayPal.com to treasurer@sjwellnesscouncil.org
I understand that my SJ Wellness Council membership is valid for the calendar year 2011, at $89.
______________________________________________________________ ____________
Signature Date