CONSULTANT INFORMATION
* First Name:
* Last Name:
* Date of Birth:	-Month-JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember -Date-12345678910111213141516171819202122232425262728293031 -Year-19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006
Social Security No:
* Address:
Apt No:
* City:
* County:
* State:	Please SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTMXNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVTWAWIWVWY
* Zip/Postal Code:
* Phone Number:
Mobile Number:
Fax Number:
* Email Address:
SPONSOR INFORMATION
First Name:
Last Name:
Sponsor ID:
ORDER INFORMATION
BASIC KIT - $ 29.99 + tax and shipping (website set up, one month of website fees - $ 10, catalogs, sales forms, business opportunity brochures, Policies and Procedures Manual, Reward Points Book, Recruiting Flipchart, other literature). APPROXIMATE TOTAL VALUE - $ 130+ BASIC PLUS KIT - $ 99.99 + tax and shipping ($ 200 retail value jewelry, Hostess gift, portable jewelry case, packaging materials, website set up, one month of website fees - $ 10, catalogs, sales forms, business opportunity brochures, Policies and Procedures Manual, Reward Points Book, Recruiting Flipchart, other literature). APPROXIMATE TOTAL VALUE - $ 400+ PREMIUM KIT - $ 199.99 + tax and shipping ($ 400 retail value jewelry, jewelry displays and packaging materials, Déaxis tote bag, Hostess gift, portable jewelry case, postcards, website set up, one month of website fees - $ 10, catalogs, sales forms, business opportunity brochures, Policies and Procedures Manual, Reward Points Book, Recruiting Flipchart, other literature). APPROXIMATE TOTAL VALUE - $ 700+
Would you like to select your own jewelry samples for the Basic Plus Kit or Premium Kit? Yes, I want to select my own samples. No, I want Déaxis staff to put together the sampler for me.

Please have your debit/credit card information ready to pay for your Starter Kit.