* - denotes required field

Sponsor:	Dubouchez, Raphaël (5459)
State:

First Name: *			Last Name: *
Company:			SSN/TaxID/Govt ID:*

Date of Birth (MM/DD/YYYY): *

Primary Phone: *			Fax:
###-###-####
Work:			Mobile Phone:
Email: *

Billing Country: *
Bill Street1: *
Bill Street2:
Bill Postal Code: *		State: *
Billing City: *		Bill County: *

Click here if Shipping Information is the same as Billing Information

Ship Country:	FRANCE
Ship Street1
Ship Street2
Ship Postal Code		Ship State
Ship City		Ship County
Ship Phone


www.site.com/
When you become a registered QuantumLifestyle Independent Consultant, you will have immediate access to your personal QuantumLifestyle replicated website to direct your customers and potential new Independent consultants to. Please enter your desired “site name” in the box above. For example if you want EmilySmith.QuantumLifestyle.com/ enter “EmilySmith” in the box above. Your personal QuantumLifestyle website also provides an About Me page where you can tell customers a little bit about yourself. Use the Replicated Site Text box below to provide some information about yourself such as who you are and why you joined QuantumLifestyle.

Replicated Site Text (max XXXX chars):

8 or more chars, include at least 1 upper case and lower case letter, number, and special character
Extranet Password:*
Confirm Password:*

Starter Pack - 39.95

New Affiliate Member Pack
Includes:

Download of Acupressure Using Holographic Technology Book

1 Year Personalized Back Office

1 Year Personalized Shopping Cart

1 FREE Hologram Sample Pack - $59.95 Value
(12-Relief, 12-Energy, 12-Sleep)

Print This Page

Click here if you agree to the Enrollment Terms as presented here. You cannot continue without agreeing to the Enrollment Terms.

Please read and agree to all of the listed Enrollment Disclaimers as well as the Affiliate Agreement. By clicking "I agree" and continuing you agree to have read all of the following documentation and accept to do business with and on behalf of Quantum Lifestyle and these terms:

Quantum Lifestyle Affiliate Agreement

Policies and Procedures

Privacy Policy

Terms of Use