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 #*
Time Zone Your Lead resides in*

PacificMountainCentralEastern
Your Lead's Address

Street Address

Street Address Line 2

CityState

Zip Code
Device your lead is interested in

HERO X1 or X2 (12 volt)HERO PROHERO PRO TOTEHERO PRO X2Magnus Pro X1 MPMagnus Pro X2 MPMagnus Pro X1 HPMagnus Pro X2 HPSpark Gap DeviceZoo Hoof Pro SystemOther
Any additional information about your Lead's use?
Enter any information about the person you are referring that you think is important
It is important to your Lead that*

A PEMF Device has received an Electrical Safety Testing Certificate ( CE Mark or UL)The manufacturer protects its buyers and users with a Product Liability PolicyIs FEI Compliant (generates less than 1,000 Gauss maximum output)None of the above is important
My Lead is interested in a PEMF Device for use on:
Human Use

Medical DoctorNaturepathChiropracticIntegrative MedicinePhysical TherapySports TeamSports TherapyOther
Animal Use:*

HumansEquineSmall AnimalsLivestockSea MammalsOtherExotics
Your Lead will use in the animal world as a

Licensed VetEquine TherapistTrainerCompetitorGroomerHandlerStable OwnerOther
Your Name*

First NameLast Name
Your Phone Number*
Your E-mail*
example@example.com
I am ready to submit my Lead*

YesNo
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
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Submit your Lead Here!

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