HeartMath VIP Client Agreement

Welcome to our VIP client application form. Please fill out everything below. If you have any questions please contact Jessie Rohrer by email jessie@heartmath.com or direct line: (831)338-8785.

1. Company Name: *This question is required.

2. Company Project Manager Information (HeartMath's Contact): *This question is required.

Name:
Email:
Phone Number:

3. Client Goal for the VIP Program: *This question is required.

4. If goal is achieved, # of employees targeted for the next 12 months:

5. Number or VIP Program Participants? *This question is required. This question requires a valid number format.

6. Program Participant information

Space Cell	Name & Title	Email	Phone
1. *This question is required	Name & Title	Email	Phone
2.	Name & Title	Email	Phone
3.	Name & Title	Email	Phone
4.	Name & Title	Email	Phone
5.	Name & Title	Email	Phone
6.	Name & Title	Email	Phone
7.	Name & Title	Email	Phone
8.	Name & Title	Email	Phone

7. Where would you like all of the participant materials (emWave PSR's & Class Workbooks) shipped to?

First Name *This question is required.

Last Name *This question is required.

Company Name; if Company Address

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Country *This question is required.

Email Address *This question is required.

Phone Number *This question is required.

8. I, the undersigned understand and agree to the Nondisclosure of Confidential Material:
Confidential Material will be used solely for the purpose(s) for which it was exchanged and the recipient of Confidential Material will use the same care and discretion to avoid disclosure of the Confidential Material as it uses with its own similar information that it does not wish to disclose; provided, however, that any Confidential Material may be disclosed to the receiving party's employees and contractors and the employees and contractors of Affiliates who have a need to know such information for the same purpose(s) (it being understood that such employees and contractors shall be informed of the confidential nature of such Confidential Material and shall be directed not to disclose such Confidential Material and to use such Confidential Material solely for the purpose(s) for which it was originally exchanged).

The Confidential Material will not be used to develop, sell, or market products or services without the express written consent of the disclosing party. Company shall not develop, sell, or market projects or services utilizing any form of such Confidential Material. *This question is required.

Please type Employee signature (full name) in box below indicating you agree to the Nondisclosure Agreement.

HeartMath VIP Client Agreement

Company/Organization/Participant Information