Eagle Medical Group LLC Sales Kit Order Form

Name: __________________________________________________________

Address: __________________________________________________________

___________________________________________________________

City: ________________________ State: _________________ Zip: __________

Phone #: ( ) _______________ Cell Phone #: ( ) ______________________

Fax: ( ) _________________ E-mail: _________________________________

Social Security #: ________________________

Or

Name Of Company:___________________________________________________

EIN #: _______________________________

Sponsor’s Name:________________ Sponsor’s ID # if any: ____________________

Sales Kit Consists of:

(1) Bio-Back

(2) Business Cards

(3) Training Manuals

(4) Marketing Materials including brochures

(5) Bio-Back Inservice DVD

(6) Full Sales Support From Eagle Medical

Enclosed is a check or money order for $202.95 (Bio Back $193.00 plus $9.95 shipping and handling) made out to Eagle Medical Group. Please mail the Sales Kit to the above address.