Myokin Inc. Presents:  Michael Uriarte D.C. the Developer of the

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ORDER/REGISTRATION FORM
Mail or Fax in:

Name: _____________________________________

Address: __________________________________________

City: _______________________     State: __________    Zip: _______________

Phone: (_____)______________   (_____)___________________
             work                                           home

email address: ___________________________________________________

Class Location and Date: _________________________________________
or
Home Study Course with DVD

Upper Body Home Study     Lower Body Home Study      Upper and Lower
($495.00 plus s&h)                ($495.00 plus s&h)             ($875.00 NO s&h)**

8 hr Headache Home Study,    8 hr Plantar Fasciitis Home Study
($199.00 plus s&h)                     ($199.00 plus s&h)                        

Shoulder Injury            Golfers Elbow        Carpal Tunnel
($119.00 plus s&h)    ($119.00 plus s&h)    ($119.00 plus s&h)

Low Back Injury            Sciatica                    No CE Credit for the $119.00
($119.00 plus s&h)    ($119.00 plus s&h)    home courses

Credit card # _____________________________________  Exp. Date: _________

Name on card: ______________________  Signature: ______________________

If Visa, last 3 digits on back where you sign name: ______________________
Amount authorized to charge to card: _________________________
**Continental U.S. orders only. International orders call for shipping cost.
Home study return policy: The product we are selling with this home study course
is knowledge, therefore, we cannot accept returns once this has been opened. If
you find any DVD to be defective, simply let us know and you may
return the defective DVD to us and we will mail you a replacement.

Please print, fill out and mail or fax to:
MyoKin Inc.
P.O. Box 27187
Shawnee Mission KS. 66225
Fax # 913-649-7023

mike@myokinesthetic.com   email address