Customer Application

Preferred Customer Membership Application

Application Information

All information in this section must be completed to be eligible for membership.

Home Telephone #:		EX: xxx-xxx-xxxx
Email Address:
Your Name:		Last, First, Middle
Co-Applicant's Name:		Last, First, Middle
Street Address:
City:
State:
Zip Code:

Referrer Information

If you do not have a referrer, you may skip this section of the application.

Referred By: Last, First, Middle

Privacy Policy

Because we respect the privacy of our customers, potential customers, and all visitors in general, the following guidelines were designed to ensure these obligations are met.

Application Information: Any/all information sent to us via the application above will not be used or collected for the purposes of reselling to a third party and will not be added to a 3rd party database.

E-Mail: Any/all e-mail addresses sent to us as the result of correspondence with customers or potential customers of Evalife will not be used or collected for the purposes of reselling to a third party and will not be added to a 3rd party bulk e-mailing list. We do however keep your e-mail on file in the event that we have news about a product that may be of interest to you in the future. If you do not wish to receive such electronic mailings from Evalife, please let us know.