Broker Form

Employer Information
Contact Name*

First NameLast Name
Contact Email Address*
example@example.com
Contact Phone Number*
Please enter a valid phone number.
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Mental Health Connect Launch Date
Approximate Number of Certificates on Launch*
Actual billing of subscription fees will be based on confirmed number of employees to be uploaded to the EHN Employee Management Portal on the 1st of every month.
Service Language Preference*

EnglishFrenchBoth

Billing Information
Is billing information the same as contact information?*

YesNo
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please specify the advisor commission to be included (up to a maximum of 10%)*
%
Additional Comments or notes
Please verify that you are human*
Should be Empty:

Broker Sign-Up Form