License Application

Description:

Weight2Lose Clinics provides health oriented entrepreneurs and/or organizations the opportunity to license the Weight2Lose brand and benefit from its proven systems, programs and operational expertise in the medical weight loss and chronic disease care market.

Application Objective:

To determine mutual compatibility, we ask you to please complete this form for careful evaluation by Weight2Lose management. The information supplied will be held in strict confidence and only be utilized for evaluating your licensing candidacy.

Thank you for your interest in Weight2Lose Clinics!

Main Contact Name*:

Main Contact Number*:

Email Address*:

Your Web Address: (if applicable)

Your Corporate Address: (if applicable)

Your Home Address: (for individuals with a home office practice)

Legal Name of Entity: (or prospective individual licensee)

Do you have a business partner/s?
YesNo

Entity Registration Number: (if applicable)

Type of entity: (corporation, partnership, individual practice, etc.)

Entity active since: (or private practice)

Nature of your Healthcare Practice/ Business:

Explain Why You Want To Become A Weight2lose Clinics Licensee: (Please Elaborate)*

Do you currently own or lease space available for integrating Weight2Lose Clinics practice?
YesNo

IF YES, please describe space. (# offices available, reception area, etc.)
IF NO, please describe your plan for securing a site. (e.g. looking for placement into an active clinic/gym, in-home practice, etc.)

Indicate your preferred launch date: