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HOLISTIC MACHINE MEMBERSHIP APPLICATION

Complete This Form

Name:
Company
Street Address:
City:
State:	Province:
Country
Zip/Postal Code:
Phone:
Fax:
E-Mail:

Package Selection:

Machine Provider Profile:
Certification:	Choose up to 3 items by holding down the <Ctrl> key
Modalities Offered:	Choose up to 3 items by holding down the <Ctrl> key Other (specify):
Product Price List:	You may send your price list by e-mail to: customerservice@atlantisnatural.com Or by fax at: 786-513-8156
Patient Results:	Please specify example results you have seen in your practice as a result of patients using your product(s).
	Yes, I would like to receive monthly updates from Atlantis Energy Network

Terms of this Application:
By submitting this application I acknowledge that in no way may the machine(s) offered by me make any medical claims, or promise cures. I assume full liability for machine performance. Under no circumstances will the liability of Atlantis Energy Network exceed $100. I agree not to use the Atlantis Energy Network or Atlantis Natural name or logo without prior written consent. I also understand that Atlantis Energy Network is under no obligation to accept my application and to offer my machine(s) for sale on this website unless these machine(s) are determined to be consistent with the quality policy stated in this website. Atlantis Energy Network may use its discretion to ensure that holistic machine providers listed on this website offer products that are complementary to one another.

I agree that if my application is accepted by Atlantis Energy Network, I will be responsible for all services related to sales and delivery of my machine, including payment, shipping and handling.

Atlantis Energy Network will provide a written record of sales leads received and the holistic machine provider will be responsible for issuing monthly progress reports on the progress of those leads. A finders fee will be paid by the holistic machine provider to Atlantis Energy Network, to be negotiated upon mutual acceptance of this application. Specific details of my business arrangement with DIEX. LLC (the corporation under which Atlantis Energy Network resides) will be documented under a separate binding agreement.

By submitting this application I accept these terms.

See our full catalog of natural health products for adults and children at www.atlantisnatural.com

Copyright© 2002-2004 DIEX, LLC. All Rights Reserved. WE MAKE NO MEDICAL CLAIMS -
INFORMATION ON THIS SITE IS NOT INTENDED TO REPLACE THE ADVICE OF YOUR DOCTOR. UNLESS OTHERWISE INDICATED, STATEMENTS HAVE NOT BEEN EVALUATED BY THE FOOD AND DRUG ADMINISTRATION. PRODUCTS ARE NOT INTENDED TO DIAGNOSE, TREAT, CURE OR PREVENT ANY DISEASE. ALWAYS CONSULT YOUR DOCTOR PRIOR TO STARTING OR MODIFYING ANY HEALTH CARE PROGRAM, IF YOU HAVE A KNOWN MEDICAL CONDITION, OR IF YOU ARE PREGNANT OR LACTATING.