Diamond Registration

Registration For 20% OFF Personal Purchases

First Name

Last Name

Company Name

Phone

Cell Phone

Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Date Business Commenced:

Choose Business Type

Choose how will you be selling MyND Products

SSN or EIN

Please upload your Reseller Certificate

Please upload your Drivers Lic. or ID

Please upload your Business License

NOTE: When you click SUBMIT you will be routed to complete the Affiliate Program Registration Form.

You must complete this form separately for creation of your unique Affiliate link.