International Standard Referral Form

Submit your Lead Here!

International Buyers Only
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 *
Lead's Phone #

Area CodePhone Number
Your Lead's Location*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
What model PEMF device is your Lead interested in?
Enter any information about the person you are referring that you think is important
Your Lead is interested in a PEMF Device for use on:
Use:*

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

Licensed VetEquine TherapistTrainerCompetitorGroomerHandlerStable OwnerOther
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 (FEI Compliant-generates less than 1,000 Gauss maximum output)None of the above is important
Human Use

Personal useMedical DoctorNaturepathChiropracticIntegrative MedicinePhysical TherapySports TeamSports TherapyOther
Your Name*

First NameLast Name
Your Phone Number*

Area CodePhone Number
Your E-mail*
You use this email for your PayPal Account?

YesNo
Your PayPal email
example@example.com
Do you own a PEMF Device?*

Any Magnus Pro ModelAny EquiPulse ModelDo not yet own a PEMF Device
I am ready to submit my Lead*

YesNo
You 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*

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

Submit your Lead Here!

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