Genewize Application for Enrollment

NAME_____________________________DATE OF BIRTH______/______/______ ADDRESS_________________________CITY___________STATE_____ZIP_______ PHONE #_________________________________SSN#_______-_______-_______ CREDIT CARD________________________EXP DATE_____________CVV________ EMAIL ADDRESS_____________________________________________________ Billing address different from above_____________________________________ Website name www.mygenewize.com/_________________alt._______________ Password:________________________ (6 characters minimum) LifeMap Me Nutritional Supplement w/Free DNA Assessment - $129 includes: DNA Test, results and report, Initial 30 Day supply of LifeMap Me Supplement Essentials (Non Custom Formula).

LifeMap Me Skin Repair Serum w/Free DNA Assessment - $129 includes: DNA Test, results and report, Initial 30 Day supply of LifeMap Me Skin Repair Serum Essentials (Non Custom Formula).

Basic Business Kit - $59 includes: LifeMap Magazine w/DNA Collection Kit, 1 Pkg. of Opportunity Post Cards, Free Basic Website, 1-month FREE Pro Website (w/marketing tools and GeneWize Academy w/certification; Value - $19.95), Enroll Four and Pay No More Benefit, Getting Started Business Guide.

Executive Business Kit – $99 includes: (4) LifeMap Magazines w/DNA Collection Kit (Value $26), (2) Pkg. of Opportunity Post Cards (Value: $10), Free Basic Website, 1-month FREE Pro Website (w/marketing tools and GeneWize Academy w/certification; Value - $19.95), Enroll Four and Pay No More Benefit, Getting Started Business Guide, 1 Package (45) of Alert Chocolate Chews (Value $39.95), 2 Packages (30 in each) of Serum Sample Sachets (Value – $30).