Please print this form, fill it in and either e-mail it us at [email protected], or snail mail it back to the address below.

 

Mailing Address:

PheroTruth.com 10106 Technology Blvd. West #632 Dallas TX 75220 E-mail address: [email protected]

Account Information

Username

Email

Parent / Guardian Details

Full Name:

Relation:

Phone #:

Email

I acknowledge that the information I have provided is truthful, and understand that any information may be changed in the future by entering the User Control Panel and this user account can be removed by request.

Date: