Hgh Plus Referral Questionnaire

Name:_______________________________________

Company:____________________________________

Checks payable to:_____________________________

Address: _____________________________________

____________________________________________

City: ________________________________________

State:________________________________________

Zip Code:_____________________________________

Country:______________________________________

Web Address/URL :_____________________________

Program You are interested in:

____ Hgh Plus Referral Program

___ Personalized Health CD Program

___ Both

I understand that I may not promote these products/services or this Referral Program by sending unsolicited mailings (SPAM). I also agree to adhere to the Policies established by DMI per this program.