International Standard Referral Form

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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
Device your Referral is interested in
Use:
Human Use
Your Referral will use in the animal world as a
It is important to your Lead that
Your Name

First NameLast Name
Your Phone Number

Area CodePhone Number
Your E-mail
You use this email for your PayPal Account?
Your PayPal email
example@example.com
Do you own a PEMF Device?
I am ready to submit my Lead
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:

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