Peanut Ball Ambassador Application

First Name

Last Name

Daytime Phone

Evening Phone

Address Line 1

Address Line 2

City

State

Zip Code

Country

Other Profession

How did you hear about us?

Have you purchased the Peanut Ball Ambassador Program?

Yes

Have you personally used the peanut ball?

Yes

Have you seen the peanut ball used?

Yes

When?

Where?

Do you know someone who used the peanut ball?

Yes

Was it a Client, Patient, Friend or Myself?

Did the peanut ball work?

Yes

Do you feel the peanut ball has assisted one person avoiding a C-section?

Yes

Do you have a peanut ball?

Yes

What Size?

What Brand?

Do you have any peanut ball products; i.e. power point, book?

Yes

Do you need a tip sheet on how to get the peanut ball information form completed?

Yes

Have you been to a training on how to correctly use the peanut ball?

Yes

Where?

The name of who taught it?

Do you want more information on being an Authorized Peanut Ball Trainer to do in-services?

Yes

Do want to donate a peanut ball and peanut ball poster to my hospital?

Yes

Do want more information on a peanut ball in-service for nurses or doulas?

Yes

Do you want to schedule a consult call about the peanut ball?

Yes

Please share your Instagram name to promote you as an Ambassador.

Please share your Facebook name to promote you as an Ambassador.

Please share your professional website to promote you as an Ambassador.

Would you like to share a story about how the peanut ball worked?

Other

I understand I do have to purchase the Peanut Ball Ambassador course materials. Peanut Ball book, Course, Set of 5 Peanut Ball charts and Ambassador pin products under Peanut Ball Ambassador bundle to be an Ambassador

I understand I DO have to purchase the Peanut Ball Ambassador course materials: The Peanut Ball book, Course, Set of 5 Peanut Ball Charts and Ambassador Pin products under Peanut Ball Ambassador bundle to be an Ambassador.

Please Select One

I have purchased the Peanut Ball Ambassador Program in the store.

I have NOT purchased the Peanut Ball Ambassador Program in the store yet. But I understand I still need to purchase it.