ADDRESS__________________________
CITY_______________________ STATE______ ZIP___________
EMAIL_______________________
PHONE______________________
CHOOSE A USERNAME _______________________
CHOOSE A PASSWORD ________________________
HINT QUESTION FOR LOST PASSWORD: MOTHERS MAIDEN NAME
ANSWER FOR HINT QUESTION___________________
HOW DID YOU FIND OUT ABOUT THIS SITE?
__LINK FROM ANOTHER SITE. SITE NAME______________________
__SEARCH ENGINE
__FRIEND
__AD IN MAIL
__MAGAZINE AD. NAME MAGAZINE_________________
__OTHER. PLEASE DESCRIBE___________________________________
Please mail, along with check for $35.00, to:
Paragon Health Solutions
161 Glo-Min Drive
Pittsburgh, PA 15241
I will email you confirmation
of payment and if everything is OK with your password and username.
Thank you very much for joining!