Peanut Ball Ambassador Application First Name Last Name Email Daytime Phone Evening Phone Address Line 1 Address Line 2 City State Zip Code Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSão Tomé and PríncipeSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweWhat is your Profession? Mom Nurse ICAN Member Childbirth Educator Doula OtherOther Profession How did you hear about us? Have you purchased the Peanut Ball Ambassador Program? Yes NoHave you personally used the peanut ball? Yes NoCheckbox GridLove itLike itIt's OkayDon't Like ItUnsureIf so, did you like the peanut ball?Have you seen the peanut ball used? Yes NoWhen? Where? Do you know someone who used the peanut ball? Yes NoWas it a Client, Patient, Friend or Myself? Did the peanut ball work? Yes NoDo you feel the peanut ball has assisted one person avoiding a C-section? Yes NoDo you have a peanut ball? Yes NoWhat Size? What Brand? Do you have any peanut ball products; i.e. power point, book? Yes NoDo you need a tip sheet on how to get the peanut ball information form completed? Yes NoHave you been to a training on how to correctly use the peanut ball? Yes NoWhere? The name of who taught it? Do you want more information on being an Authorized Peanut Ball Trainer to do in-services? Yes NoDo want to donate a peanut ball and peanut ball poster to my hospital? Yes NoDo want more information on a peanut ball in-service for nurses or doulas? Yes NoDo you want to schedule a consult call about the peanut ball? Yes NoPlease share you Instagram name to promote you as an Ambassador. Please share you 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 not have to purchase any peanut ball products to be an ambassador. I understand I do not have to purchase any peanut ball products 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.Submit
