Advanta Provider Relations

Provider Application

Form Date: 6/7/2023

Your Name *

Title *

Facility Name *

Email Address *

Phone Number *

Do you have more than 1 location? *YesNo

Facility address

Street *

City *

State *

Zip *

Corporate address

Street *

City *

State *

Zip *

Number of Locations you own or operate *

Are the facilities located in more than one state? *YesNo

Is your facility open to the general public? *YesNo

Does your company have a clean record with the Better Business Bureau? *YesNo

Is your facility registered/bonded with the state consumer affairs department? *YesNoNot Required

Do new members receive a complimentary fitness evaluation and/or program set up? *YesNo

Are you able to track and report membership usage data electronically? *YesNo

Which amenities are included as part of a standard membership? *

(double click on the amenity to select it)

This information is for evaluation purposes and will be treated as confidential.

Email me a copy of the information I submitted on this form.