Your Name

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* 1. Your Name

Company Name

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* 2. Company Name

What is your street address?

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* 3. What is your street address?

What is your email address?

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* 4. What is your email address?

Please click the choice that best describes your business

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* 5. Please click the choice that best describes your business

Please choose the compensation structure that best fits your business

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* 6. Please choose the compensation structure that best fits your business

Do you modify the price of the care in any way?

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* 7. Do you modify the price of the care in any way?

Are all of your fees disclosed in an up-front transparent way to ALL parties involved in the transaction?

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* 8. Are all of your fees disclosed in an up-front transparent way to ALL parties involved in the transaction?

If you are a TPA or Broker, do you take ANY compensation from any party that is not your client?

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* 9. If you are a TPA or Broker, do you take ANY compensation from any party that is not your client?

Please provide two client references below

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* 10. Please provide two client references below

Are there any pending or known regulatory actions, lawsuits, or other legal actions against you or your company?

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* 11. Are there any pending or known regulatory actions, lawsuits, or other legal actions against you or your company?

Please describe who your competition is and what makes your company the best choice for our membership.

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* 12. Please describe who your competition is and what makes your company the best choice for our membership.

Do you agree to abide by the Pillars of the FMMA?

Any vendor/facilitator whose business models or practices are not consistent with the pillars will not be approved for membership. Those who sign this agreement and are later found to be violating these pillars will have their membership revoked with no refund of membership fees or endorsement expenses.

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* 13. Do you agree to abide by the Pillars of the FMMA?

Any vendor/facilitator whose business models or practices are not consistent with the pillars will not be approved for membership. Those who sign this agreement and are later found to be violating these pillars will have their membership revoked with no refund of membership fees or endorsement expenses.

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