Balanced Membership Sign up Form

First Name *

Last Name *

Address *

Address 2

City *

State/Province *

Zip/Postal Code *

Phone *

Email Address *

Membership Type *

Defined $99	Polished $179	Refined $249
Mens Wellness $200

Preferred way to contact *

Phone

Email

Any

Updated CC Number *

exp (00/00) *

CVV Code *

Billing Zip *

Terms and Conditions *

You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.

*

The credit card I have provided will be charged on the 1st of every month, or nearest business day.

I understand that signing up for an initial 3 month membership commitment, it is month to month after that.

I understand that that if I cancel my membership before the 3 month period, there is a $150 fee.

Please sign *

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