Submit Your Store Request

Complete the Form Below For New Stores & Submit Payment at the Bottom

IMPORTANT:

Store requests unfortunately Cannot Be Guaranteed, as requests are granted on a first come, first serve basis with Direct Health.

Submitting a request will commit you to staffing the store and being responsible for the fee.

Payment Information

$1500 fee per Walmart store ($450 for OEP) , Press Pay Now or use the QR Code to get started. If you don't have an account, on the next page select "Pay with Debit or Credit Card".

If you're requesting multiple stores, please submit separate payment for each location.

For Kroger Payments, press the box under "Store Count" to select the $1115 Kroger Store option.

Store Count
Requested Store Number(s)

Once your payment is processed, please email the PayPal receipt to [email protected] for verification. If your store request is not approved, JSA will provide a full refund.