Welcome To The By The Bay Health Virtual Brand Launch! – “Compassion in Action

Request for Business Cards/Photo ID

Request for Business Cards/Photo ID

FORMS MUST BE COMPLETED IN FULL TO BE PROCESSED. PLEASE PRINT CLEARLY.
DATE SUBMITTED:
- Date Submitted:
PHOTO ID BADGE
- First Name*
- Middle Name Initial
- Last Name*
- Credentials (Optional)
- Job Title
- Volunteer
  - Volunteer
- My gender pronouns are (ex. She/her/hers; he/him/his; they/them/theirs, etc.)
- I would prefer not to list my pronouns.
  - I would prefer not to list my pronouns.
BUSINESS CARDS
- First Name*
- Last Name*
- Credentials (Optional)
- Job Title*
- My gender pronouns are (ex. She/her/hers; he/him/his; they/them/theirs, etc.)
- I would prefer not to list my pronouns.
  - I would prefer not to list my pronouns.
- License No.: (if required)
- Office
  - San Francisco
- Address and Street Name
- City
- State
- Zip
- Office
  - Sonoma
- Address and Street Name
- City
- State
- Zip
- Office
  - Larkspur
- Address and Street Name
- City
- State
- Zip
- Which Service line do you work for?
- Office Number
- Mobile/Direct Number
- Note: General office number is used for all employees except managers. Managers, enter your direct office number and/or company-issued cell phone number if you want those on your business cards
- Fax Number
- Note: Employees will automatically have their site’s fax number included unless otherwise noted here
- Email*
- Note: Please enter your current email address without @hbtb.org, i.e. first initial + last name.
- Note: Due to HIPAA concerns, email addresses are not used for clinicians (except supervisors).
SUPERVISOR INFORMATION
- Supervisor Name*
- Supervisor E-mail*
T-SHIRT SIZE
- T-Shirt Size*
Comments
- Comments