Refund Request Form
There are twelve 'brief' questions below that you must answer to be eligible for
a refund on your Biolanyn purchase.

1. Is this your first order of Biolanyn?

Yes No

2. What is the batch # from the underside of your jar?

3. How many 'consecutive' days did you apply the product?

(number)
Important Note: This is actual number of 'consecutive' days that you used our
product, not the number of days that have passed since you placed your order!

4. How many times per day did you apply the product?

(number)

5. Describe any improvements to the health and appearance of your skin?

6. What is the full name of your skin condition?

7. What part(s) of your body did you treat with Biolanyn?

8. How many 'unopened' jars remain?

(number)

9. Please provide the following SHIP TO information:

Full Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
**E-mail

**Note: The person completing this form must provide a valid email address
(preferably the SHIP TO email that was used when placing the order) in order
for us to process the refund request.  If you do not have one, then ask a relative,
friend or business associate with an email address to submit the form for you.
Alternatively, you can get a FREE web based email address at
http://www.yahoo.com or http://www.hotmail.com

10. Carefully choose 'how you paid' for our product from the 'pull-down'
window immediately below ...

11. What was your Order # or Transaction ID?
It can be found in the 'Subject Line' or 'Body' of your email or online order
confirmation. For Fax or Mail orders enter "None".

12. What was your Order date?






Note: Click the 'Submit Form' button once ONLY. If you have successfully sent a
request for refund, a 'confirmation' web page will appear (usually within 1 minute)
stating "The following form submission was sent". Please allow up to 30 days
for processing of your refund request. DO NOT submit additional refund requests in
an attempt to expedite your refund.
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