New Member Registration Form

You may become a member now for $10.00 per month (or more-see Membership levels below) tax free donation. You may change the amount or cancel your membership at any time without penalty. There is a one time setup fee of $50.

Membership includes:

* Access to the scientific database of the worlds renowned medical research scientists and information on their latest research results.

* Special bulletins and reports on scientific breakthroughs available only to our members.

* Links to the actual products that have met our scientific requirements and been awarded our seal of approval.

* Knowing your contributions are being used for the benefit of mankind.

* Special video seminars only available to members.

* Members discounts by various product suppliers. This benefit alone can more than pay your membership donation.

First Name _____________________________________ Last Name ________________________________________ Age ________

Street Address _______________________________________ City ____________________________________

State _______________ Postal Code (Zip) ____________________________ Home Phone _____________________________

Company Name ________________________________________________________ My Position _________________________

Company Street Address ___________________________________ City ______________________ State _____ Zip ________

Email 1 ____________________________ Email 2 ____________________________ Fax ______________________________

Telephone 1 _________________________ Telephone 2 ________________________ Cell ____________________________

Please Check One Box for the Monthly Donation You Will Make - There is a ONE-TIME Setup Fee of $50

Level 1 - $10 Monthly Donation	Level 1 - $25 Monthly Donation	Level 8 - $700 Monthly Donation	Level 8 - $750 Monthly Donation
Level 2 - $50 Monthly Donation	Level 2 - $100 Monthly Donation	Level 9 - $800 Monthly Donation	Level 9 - $850 Monthly Donation
Level 3 - $150 Monthly Donation	Level 3 - $200 Monthly Donation	Level 10 - $900 Monthly Donation	Level 10 - $950 Monthly Donation
Level 4 - $250 Monthly Donation	Level 4 - $300 Monthly Donation	Level 11 - $1000 Monthly Donation	Level 11 - $1000 Monthly Donation
Level 5 - $350 Monthly Donation	Level 5 - $400 Monthly Donation	Level 12 - $1500 Monthly Donation	Level 12 - $2000 Monthly Donation
Level 6 - $450 Monthly Donation	Level 6 - $500 Monthly Donation	Other Options Call 877-702-1157	Annual Single Payment
Level 7 - $550 Monthly Donation	Level 7 - $600 Monthly Donation

___ Check here if you wish to receive the Rhino Charger by mail (Available to members only)

I agree to donate the amount of $ ____________________ per month, and a one time setup donation of $50.00 to the non-profit (501c3) Applied BioPhysics Ministries, to automatically be deducted from my financial account listed below. I understand that I will be a regular supporting member with exclusive benefits and access to the Members Only Area on the rhinoed.org website, and I may unsubscribe to my subscription at anytime without penalty. All donations over $250.00 will receive a written receipt.

I authorize the Applied BioPhysics Ministries to debit my Debit Card or Credit Card listed below and I will pay my monthly membership donation with the following financial account:

____ Credit Card ____ Debit Card ____ Annual Single Payment (Call) _____ By Check

Type of Card: ______________________________ (Visa, MC, Discover, American Express) Expiration Date: ______________

Name on card: _________________________________ Card No: __________________________________

Security code: ________ (3 digit number on back of card)

Authorize Signature: ____________________________________________ Date: _____________________

For assistance please call 877-702-1157 - Fax to: 801-766-7246

Or Mail to: Applied BioPhysics Ministries, 504 Saint Matthews Road, Erwin, North Carolina 28339