U.S.A. Standard Referral Form

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By filling out a blank Referral Form you hereby agree to the Policies, Terms and Conditions on this page.
Your Lead's Name

First NameLast Name
Notes
Your Lead's Email
Your Lead's Phone #
Format: (000) 000-0000.
Time Zone Your Lead resides in
Your Lead's Address

Street Address

Street Address Line 2

CityState

Zip Code
Device your lead is interested in
My Lead is interested in a PEMF Device for use on:
Animal Use:
Human Use
It is important to your Lead that
Useer in the animal world:
Any additional information about your Lead's use?
Enter any information about the person you are referring that you think is important
Your Name

First NameLast Name
Your Phone Number
Format: (000) 000-0000.
Your E-mail
example@example.com
I am ready to submit my Lead
You have just chosen to agree with all eligibility and funding Rules, Terms and Conditions as outlined in Magnus Magnetica’s now current Sales Lead and Referral Fee Program or Authorized Independant Sales Agent Program.
Submission Date

MonthDayYear
Hour MinutesAM/PM Option
Should be Empty:

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