APPLICATION FORM 
(* Required)

* NAME:  
 DOB:
* STREET:
APT/SUITE:
* CITY:
 		* STATE:
* ZIP:
* HOME PHONE:
WORK PHONE:
CELL PHONE:
 * EMAIL:
Is it safe to ship items to the above address without a signature requirement ?  YesNo
What is the no.1 area in your life that you need to transform within the next 3 months?  (Please give details)
What other advantages are you looking to gain from joining Dr. Kim's circle?
What attributes can you bring to the other V.I.P.'s in your group?
Is it okay to distribute your name and e-mail address to other V.I.P.'s in your group ?   YesNo
If this circle is full or you are not accepted into the circle for any reason, your money will be refunded.   
Please be advised that all information provided is considered strictly confidential.

 

Thank you for your interest!