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The Ohio Department of Aging

Ohio Department of Aging Golden Buckeye Program

To enroll your business in the Golden Buckeye Program please complete the form below. Required fields are marked with an asterisk (*).
Business Contact Information
* Business Name:

* Service Location Address:

* City: * State: * Zip: - Multiple Locations:
Our Mailing Address is Different Than the One Above

* Business Phone: Business Fax: Website:
(999-999-9999)
(999-999-9999)
(www.mysite.com)

   
 
 
 
 
 
 
Business Details
Our locations(s) is handicap accessible.
Our locations(s) features handicap parking.

We accept these forms of payment:

Cash
Visa
Discover
Other

Check
MasterCard
American Express

 
Appropriate Merchant Classifications
In the text box below please provide a simple description of the business or service provided. You may then choose classifications for the business or service by clicking on a heading like 'Cars and Transportation' or 'Food and Drink' and checking the box next to the appropriate description(s). Please choose no more than five. These classifications will be employed in searches by visitors to the Department of Aging's 'Golden Buckeye Merchant Search' page.


Too many business classifications selected. Please select no more than 5 classifications below.
Cars and Transportation
Auto body, paint, glass, interior repair
Auto parts, accessories
Auto repair, maintenance
Batteries
Body repair

Bus service
Auto body, paint, glass, interior repair
Car washes
Collision services
Driving schools, instruction

Gas stations
Motorcycle sales, service
New cars
Oil change, lubrication
Parking lots, garages

RV and camper sales, service
Salvage yards, used parts
Taxis, limousines, ambulance
Tires
Towing

Food and Drink
Health, Wellness, and Medical
Home Services and Contractors
Personal Care
Pets
Professional Services
Recreation, Entertainment and Education
Shopping
Travel
Benefit 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.

$ off

Free

Other:

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 with the Ohio Department of Aging (the department) to honor the Golden Buckeye card (the card) for products and services provided to eligible Ohioans (those age 60 or older and those 18 and older who have total and permanent disabilities). We agree to make no change in the regular price for goods and services before honoring the card.

We understand that acceptance in the program does not imply an endorsement of our business by the department or Golden Buckeye Program (the program) of our products or services and we will not use Golden Buckeye 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 department. We also acknowledge that this agreement remains in effect unless canceled in writing by us or by the department and that violation of the above terms may result in automatic removal from the program.

* Business Representative: Title:

Email Address: * Phone:
(999-999-9999)
(email@mysite.com)

 
 
 
Golden Buckeye Program Signage
Order your FREE Golden Buckeye signage below. Decals will be sent to the mailing address specified in the Participation Agreement. You may also request that a logo image and/or a table tent in ".jpg" electronic format be sent to you at the email address entered above. These are suitable for use on your web site and in promotional materials. Please be sure that you have entered your email address in the "Agreement" section above if you are requesting logo images or table tents.

Golden Buckeye Program signage
Self-sticking window decals.
Quantity 2: 

Golden Buckeye Program signage
 Table tent (Golden Buckeye Card Honored Here!).

Golden Buckeye Program signage
 Electronic Golden Buckeye Logo.

To submit this Business Participation Agreement enter the text you see below and click "Submit"