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Affiliate Organization Form
Organization/Company name
*
Registration Number (Company/Business Registration)
*
Organization Address (Street, City, State, Zip Code)
*
Organization Type (Select the most appropriate category for your organization)
*
Healthcare Provider
Elderly Care Service Provider
Wellness and Fitness
Community-Based Organization
Educational Institution
Non-Profit
Other
Please Specify Other
Website URL (Optional)
Social Media Profiles (Enter relevant social media links, if applicable)
Contact Person (Full Name)
*
Position/Title (Enter the contact person’s position within the organization)
*
Email Address (Enter a valid email address for communication)
*
Contact Number (Phone/Office Line)
*
How Did You Hear About KENDANA?
*
Social Media
Word of Mouth
Online Search
Event or Conference
Other
Please Specify Other
Why Do You Want to Become a KENDANA Affiliate?
*
Target Audience for Referrals (Select the primary audience you plan to refer to KENDANA)
*
Individuals Seeking Care
Families Needing Caregivers
Online Search
Caregiver Organizations
Health and Wellness Providers
Other
Please Specify Other
Submit
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