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Licensing Information

Thank you for your interest in the Geri-FitŪ Instructor License. Please complete the online license application below. You may skip any questions that you don’t feel comfortable answering or that do not apply to you. If you are a facility or applying for more than one location, please use the Facility Application instead. This form is only to be used by Instructors that would like to become licensed. Once your application is received, a Geri-Fit representative will contact you within 48 hours. This application is for quote purposes only and does not bind you to purchase anything.

Personal Information
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Company/Facility:
Years in Business:

License Information
License will be purchased for:
Myself (as a vendor or contractor providing services - not an employee)
My company or LLC
My church or faith-based organization - single location only
Other:
Facility where classes will be held:
At how many locations are you planning to teach class?
In which cities, townships or counties do you wish to offer class?
When are you planning to begin class?
Will you be the instructor?
Yes  No

General Information
How did you hear about Geri-FitŪ?
Have you ever taken Geri-FitŪ before?
Yes  No
If yes, where and when?
Have you ever owned your own business or franchise?
Yes  No
Please share any training or background experience relevant to becoming a Geri-FitŪ licensee?
Training, Certifications, or Licenses (PT, OT, Instructor, etc.):
List any hobbies, community activities, special interests or other relevant information:

Background Information
Of which country are you a citizen?
Have you ever been convicted of anything other than a minor traffic violation?
Yes  No
Has any judgment ever been entered against you, your company or your employer where you were one of the litigants?
Yes  No
Are you involved in a pending litigation?
Yes  No
Have you or your spouse ever declared personal bankruptcy?
Yes  No
If you answered yes to any of the above questions, please explain:

References (optional)
Please list three references, excluding employers and relatives:
Reference #1
Name: Address: Phone: Years Known:
Reference #2
Name: Address: Phone: Years Known:
Reference #3
Name: Address: Phone: Years Known:
 
Please complete the following statement, I am confident
I can be a successful Geri-FitŪ Program Licensee because
:
Comments or Questions:

Acknowledgement
By submitting this application, I hereby acknowledge the information in the application to be true and correct. I understand that this application is in no way binding to the applicant or GERI-FIT COMPANY LLC, and that this information will be used to assess the suitability and qualifications of the applicant. I understand that any information I may receive from GERI-FIT COMPANY LLC is confidential and may not be used or shared without the consent of GERI-FIT COMPANY LLC.