Become a Lifetherapy Leader

 

Contact/Tax Information

Name *
Prefix
First *
Last *
Suffix
MI
Middle
Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Birthdate *

MM
/
DD
/
YYYY
Must be over 18 Years of Age
SSN (Tax ID)
Main Phone *

###
-
###
-
####
Alternate Phone

###
-
###
-
####
Email *

Choose a Tier

Select a kit *
 Launch Kit ($198) 
 Positivity Kit ($298) 
 Mood Boosting Kit ($398) 
Name on Credit Card *
Credit Card Number *
Card will not be billed until you have been approved for the Lifetherapy Leaders Program
CVV Number *
Card Expiration Date *

DD
/
MM
/
YYYY

Every Lifetherapy Leader is provided with a Unigue URL, and profie page.

Preferred URL name *
No more than 15 characters
example: username.lifetherapy.com
Second URL choice
if first is not availabe
Please include the following information on my profile page *
 Address 
 Phone Number 
 Email Address 
Image for Profile Page *
Give us a short Bio *
This bio appears on your profile page.
Tell your customer your favorite product from Lifetherapy *
Add a second
And a third

Agreements and Terms

You must read and agree to all the forms listed below.

Checkbox *
 I have read the E-Signature Policy 
Signature *
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