Membership Application Form

Membership includes 15% discount on all items in the store except products purchased locally.
New members will receive free up to 12 Life Extension monthly magazines.
Three (3) family members or close friends can be included in account.
We keep a detailed record of all members’ purchases in case past supplement use needs to be researched.
Membership & Renewal Cost: $100 per year.

First Name *

Last Name *

Address *

City *

State *

Zip *

Country *

Phone (H) *

Phone (O)

Family Members

Email *

Payment for *

New Membership

Renew Membership

Date of Birth *

Total Amount

Payment method

Pay by Credit/Debit Card

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*