Membership application form

MEMBERSHIP GUIDE

Application

Holistic study group for cancers, diabetes & incurable diseases

Member Information

Member Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Date of Birth

Surgery History

Gender

If Yes, for what?

Disease Confirmation Letter: Clinic Charts (Copies, Photos)

Link to Membership Policy

I fully understand and agree to the membership policy.

Signature

Clear Signature

Date / Time

Pay via Mail

If you prefer to pay your membership fee by personal cheque, certified check or money order, follow these steps:

1. "Pay to" information: JSD CANDO HEILENE PHARMA INC.
2. Make sure the address is correct. Address your cheque to:

JSD CANDO HEILENE PHARMA INC.
565 Wilson Ave W114,
North York, ON M3H 0C6

Products will be shipped within ten business days of receiving the cheque.

Authorizations

Initial Payment

One time - $800.00

Special Membership

Special membership - $406,800.00

Special membership $360,000 + TAX(13%)

Silver Membership

Silver Yearly Plan - $10,848.00
One Bottle Plan - $904.00

Silver Yearly Plan $9,600 +TAX(13%) One Bottle Plan $800 +TAX(13%)

Gold Membership

Gold Yearly Plan (18 Bottles) - $20,340.00
One Bottle Plan - $1,130.00

Gold Yearly Plan(18 Bottles) $18,000 +TAX(13%)
One Bottle Plan (20 days) $1,000 +TAX(13%)

Total

$0.00

Payment Information

Card Number

Expiration Date

Security Code

Card Holder Name

Application