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HOLISTIC PRODUCT MEMBERSHIP APPLICATION
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Name:
Company:
Street Address:
City:
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Package Selection:

Product Provider Profile:
Certification:	Select up to 3 items by holding down the <Ctrl> key
Modalities Offered:	Select 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: dcloutier@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 products offered by me make any medical claims, or promise cures. I assume full liability for product performance. In no way will the liability of Atlantis Energy Network exceed $25. 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 products for sale on this website unless these products are determined to be consistent with the quality policy stated in this website. Atlantis Energy Network may use its discretion to ensure that holistic product 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 shipping inventory of my product to Atlantis Energy Network headquarters at the following address;

Atlantis Energy Network
P.O. Box 651592
Miami, FL 33265

Atlantis Energy Network reserves the right to change this shipping address according to business requirements. Atlantis Energy Network will provide a written record of inventory received and product sales, and will provide monthly payments for the wholesale cost of my products sold, 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 agree to 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.