Easy Registration Form for New Kyani Distributor

This is all you need to provide for registration!

Password from website or flyer:
___________________________


Name: __________________________________________________________________

Address: __________________________________________________________________

__________________________________________________________________

If shipping address is different: __________________________________________________________________

__________________________________________________________________

H ~ ___________   C ~ ___________  O ~ _____________  F ~ ______________

Email: _________________________________@_______________________________

Sponsored by: _______________  Date: ___________ Sponsor ID: __________

Yes, I agree to Starter Pack $495 and Standard Autoship per month $128    Initial: _______

SS #: _________________________ Birthday: ____________________________

Credit Card #: ____________________________Expiration Date: ____________

Name on Card: _________________________________ 3 digit code: _________

Buying in as a business ~ other form required.

Business name: ____________________________________________________

State of corporation: _____ EI N or Tax ID: ____________________________