Secure Distributorship Order Form

Discount Code - Required:

Name:

Address:

City:

State/Province:

Zip Code:

Country:

Phone Number:

Email Address:

Distributor Plan (Super $114)/(Special $59) These prices include $4.00 shipping	Price
			TOTAL AMOUNT DUE

Canada shipping add $5.00 -- Overseas Airmail add $13.00

Credit Card

Credit Card Type: MasterCardVisa

Credit Card Number:

Expiration Date:

Name of Cardholder:

Check or Money Order

If paying by check or money order, send payment to:

KKZ Company, LLC
6055 E Lake Mead Blvd #202
Las Vegas, NV 89156
or phone your order to 1-702-453-0975 (orders only)
Information: (702) 453-0975 -- Fax: (702) 453-0975