Application

Hello! Please complete the Ambassador of Health signup process below.

Personal Information
Will only be used internally and to send you gifts!

Email*

Phone number*

Street address*

Street address 2

City*

State*

Postal code*

Country*

Profile Information
The following information will be used to create your Profile Tile on our website and will appear like this:

Headshot Photo*

Prefix

First name*

Last name*

Credentials*

degrees, certifications, qualifications, associations

Clinic/Company name

City*

State*

Personal bio*

Please provide a brief 2-3 sentence bio that includes your full name, credentials/title, specialty, experience, time in the health industry, and clinic/company description.

Website URL

Facebook URL

Instagram URL

LinkedIn URL

Twitter URL

YouTube URL

Additional URL

Is there anything you'd like us to note about your Profile Tile?

Additional Information
Helps us know how to best work with and support you!

Medical discipline

Health care profession*

How did you hear about the Ambassador of Health program?*

If Referred, who were you referred by?

Why do you want to be an Ambassador of Health with Lifeboost?*

Have you already tried Lifeboost Coffee?*

Yes

If YES - Please tell us your experience with Lifeboost products and what you loved about them. (This info may be published as a review on our website)

If NO - Please tell us what type of roast are you most excited to try (light, medium, dark, decaf, or flavored) and what options work for your machine (ground, whole beans, coffee pods).

How do you plan to offer Lifeboost Coffee to your patients?*

In person

Online

Both

Do you have a Wholesale account with us?*

Yes

IF YES - Would you like your location listed on our Health Clinics page?

Yes! I have a physical location that sells Lifeboost!

No, thank you

Do you have an Affiliate account with us?*

Yes

IF YES - Please enter your Affiliate ID so we can upgrade your account

T-Shirt size*

"Modern fit" - if between sizes, suggestion is to size up

Sweatshirt size*

"Modern fit" - if between sizes, suggestion is to size up

I consent for Lifeboost Coffee, LLC to use the information and photo I provided in this application on lifeboostcoffee.com and other Lifeboost Coffee content.*

If you are unable to complete or have questions about this application, please contact us at ambassador@lifeboostcoffee.com

Application

Personal InformationWill only be used internally and to send you gifts!

Profile InformationThe following information will be used to create your Profile Tile on our website and will appear like this:

Additional InformationHelps us know how to best work with and support you!

Personal Information
Will only be used internally and to send you gifts!

Profile Information
The following information will be used to create your Profile Tile on our website and will appear like this:

Additional Information
Helps us know how to best work with and support you!