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Business Enrollment Form

To enroll your business in the Golden Mountaineer Program please complete the form below. Please provide all the requested information.

Business Contact Information

Business Name:

Service Location Address:

City:

State:
West Virginia
Zip:

County:

Multiple Locations:

Our Mailing Address is Different Than the One Above:

Business Phone:

Business Fax:

Website:

Business Details

Our location(s) is handicap accessible.

Our location(s) features handicap parking.

We accept these forms of payment:

Benefits Details

We agree to provide cardholders the following tangible benefit(s) that are not generally available to non-cardholders (complete all that apply):


% off all purchases or services rendered.
Free:
Other (ex: xx% off on Wednesdays/or other specific discounts):

Please Check the Appropriate Box(es) That Best Describe Your Eligible Golden Mountaineer Card Services:

Appropriate Merchant Classifications

In the text box below please provide a simple description of the business or service provided. These classifications will be employed in searches by visitors to the WV Bureau of Senior Services ‘Golden Mountaineer Program Business Search’ page.


Exclusions and Limitations

Please list any restrictions (excluded products/services, limited to certain days/times, limits per customer, etc.):


Agreement:

I, the undersigned, on behalf of the above named business, voluntarily enter into this good faith agreement (this “Agreement”) with the WV Bureau of Senior Services to honor the Golden Mountaineer Card (the “card”) for products and services provided to eligible West Virginians (those age 60 or older). We agree to make no change in the regular price for goods and services before honoring the Card.

We understand that acceptance in the Golden Mountaineer Program (the “Program”) does not imply an endorsement of our business by the WV Bureau of Senior Services or Program of our products and services and we will not use Program logos and names to imply such an endorsement.

We understand that our participation in the Program is effective upon approval of this Agreement by the WV Bureau of Senior Services. We also acknowledge that this Agreement remains in effect unless cancelled in writing by us or by the WV Bureau of Senior Services and that violation of the above terms may result in automatic removal from the Program.

Business Representative:

Title:

Email Address:

Phone

Facebook Cross-Promotion

Each week, we select a Golden Mountaineer Program business partner to feature on our Facebook page (www.Facebook.com). We post a welcome or a thanks for continued patronage, and include the link to that business’ own Facebook page. This additional promotion helps our page subscribers easily find and interact with businesses that honor the Golden Mountaineer Card and is offered at no cost to you. If you would like to participate in this cross-promotion, please enter your business’ Facebook page web address below.

Facebook Page Web Address:

Golden Mountaineer Program Signage

Golden Mountaineer Window Cling

Order your FREE Golden Mountaineer Program signage below. Decals will be sent to the mailing address specified in the Agreement. You may also request that an electronic formatted image be sent to you at the email address entered above. These are suitable for use on your website and in promotional materials. When requesting the electronic logo:
Please provide your intended use of the electronic logo.
Your use of the electronic logo is authorized only as long as you are a GMC providing business.

Self-Sticking Window Decals. Quantity 2:
If you would like to request an electronic logo, please provide your intended use:

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