The below form is a nomination or a request.

IF YOU ARE A MEMBER or INTERESTED MEMBER, please fill out the form below in its entirety - the more information, the better.

IF YOU ARE AN INTERESTED FITNESS FACILITY, please fill out the form as it pertains to your center's contact information.

Nominate a Club Name * First Name Last Name Email* Phone Employer Number of employees at current location Are other co-workers also interested? --CHOOSE ONE--YesNoConsidering Partners* --CHOOSE ONE--AveraBCBSMN DISCONTINUEDBlue Cross of NDFargo Public SchoolsFleet FarmHealthPartnersMedicaMidcoNorthern Plains InsurancePreferredOnePrimeWestSanford Health PlanSioux Falls School DistrictSouth Country AllianceUCareI'm a Club Club Name* Club Address * Club Street Address Club Address Line 2 City --None--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State Zip Code Club's Phone Number* Club Manager's Name* Club Manager's Email Club Manager's Fax Club's Website Are You A Member? * --None--YesNoConsidering MembershipI'm a Club Please encourage other co-workers to complete this form, if they are interested as well.