멤버십 신청서

멤버십 가이드

애플리케이션

암, 당뇨병 및 난치병에 대한 전체론적 연구 그룹

이 양식을 작성하려면 브라우저에서 JavaScript를 활성화하십시오.

Member Information

Member Name

첫 번째

마지막

Address

Address Line 1

Address Line 2

도시

State / Province / Region

Postal Code

국가

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

애플리케이션