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Register Your Interest
Send us your expression of interest in becoming a Lift for Life licensed Provider. If you meet the criteria in regards to access to strength training equipment and qualified personnel complete this online form. You will then receive an email with information on how to become a licensed provider.
Name
"Name" is a mandatory field.
Business Email
"Business Email" is a mandatory field.
"Business Email" must be a valid email address.
Phone number
"Phone number" is a mandatory field.
"Phone number" must be a number.
Business name
"Business name" is a mandatory field.
Business address
"Business address" is a mandatory field.
Suburb
"Suburb" is a mandatory field.
State
"State" is a mandatory field.
Postcode
"Postcode" is a mandatory field.
Business contact number
"Business contact number" is a mandatory field.
"Business contact number" must be a number.
Business website address
How did you find out about the Lift for Life program?
"How did you find out about the Lift for Life program?" is a mandatory field.
What best describes your business?
"What best describes your business?" is a mandatory field.
What fitness services do you currently offer in your business?
"What fitness services do you currently offer in your business?" is a mandatory field.
What other licensed programs do you deliver?
"What other licensed programs do you deliver?" is a mandatory field.
How would you describe the culture of your business?
"How would you describe the culture of your business?" is a mandatory field.
How long has your business been operating?
"How long has your business been operating?" is a mandatory field.
Please describe why you are interested in the Lift for Life program.
"Please describe why you are interested in the Lift for Life program." is a mandatory field.
Additional Comments