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FitBit Order Form (employees only)

  1. AmFitLogo.png

  2. Fitbit Order Form

    Special pricing is available to all members of the Amherst Pelham Health Claims Trust (APHCT). Non-members also receive a smaller discount on Fitbit orders.

  3. department in which you work

  4. Are you a member of the Amherst Pelham Health Claims Trust?*

  5. Insurer

  6. $60 each (limited to 1 per enrolled member)

  7. $40 each (limited to 1 per enrolled member; if family plan, can purchase up to # enrolled)

  8. $120 each

  9. $80 each

  10. (member price * member order quantity) + (non-member price * non-member order quantity)

  11. Payment / Payroll Authorization

    Your order is not complete until payment has been received. You can pay for your order by authorizing a one-time payroll deduction or pay by check or money order. If paying by check or money order, please submit this order form and bring a check/money order, payable to Amherst Pelham Health Trust, to Human Resources Department, Mezzanine, Town Hall, 4 Boltwood Ave, Amherst.

  12. Payment Type

  13. Payroll Authorization:

  14. Payment by check or money order:

  15. Please allow approximately 3 weeks for delivery, after your order is completed.

    You will be notified when the device arrives. For questions on orders, please contact Jennifer Ortiz at / 413-362-1895 or Joanne Misiaszek at / 413-259-3003

  16. Leave This Blank:

  17. This field is not part of the form submission.