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DOT
Health Promotion

POWER
New Member Application

Please test this form prior to submitting your application on line, to ensure that there are no server problems that will interfere with the submission of your application.

In order to test the form:
  1. Type your name into the name section;
  2. Scroll down to the bottom of the page and press the "submit" button;
  3. You will be asked to review the information you typed in;
  4. Press the "finish" button;
  5. If the survey is working correctly, you will be forwarded to a page that thanks you for completing the application.
Click here to view the form

If you receive a notification that the test form was successfully sent to POWER, fill out and submit your on-line POWER application. If you receive an error message, please try back at a later time or print the application and return it to our office.



 
DOT
Health Promotion
339 Baker University Center
Tel:  740-593-4742     Fax: 740-593-0223

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