7025 E.

Greenway Parkway #250

Scottsdale, AZ 85254
USA: 1-877-281-8333 FAX: 1-877-281-8322
Non USA: +1-480-998-3490 FAX: +1-480-998-3582
Customer Service: 1-480-998-3490, Ext 3
Customer Service Email: cs@knownowfoundation.org

Know Now Foundation Ambassador Registration Form

Please complete, sign and fax to the applicable fax number above.

_____________________________________________ ____________________________
Your Name or Name of Organization / Company Primary Phone Number

_____________________________________________________________________________
If Joining by Name of Organization / Company, Contact Person’s Name, Phone & Email

______________________________ ____________________________________________
Alternate Phone Number Primary Email Address

_____________________________________________________________________________
Street Address City State/Province Zip/Postal Code

______________________________________________________ ___________________
Your Sponsors Name Sponsor’s Plexus ID#

________________________________________________ ____/____/____
New KNFA’s Signature Date of Signature
Purpose of Gift
q Please accept my purchase as a direct gift to KNF and include the KNF 50% Matching Gift
q Please ship my purchase to the address above (Shipping charges will apply)
q 1-Time Gift (This purchase will NOT be automatically executed on a monthly basis.)
q Monthly Gift (This purchase WILL be automatically executed each month and can be shipped
to the destination of your choice or gifted directly to KNF.)

Amount of Breast Chek Kit Gift (Shipping is added to purchases NOT gifted to KNF)
q Goodwill Ambassador 4 Breast Chek Kits / $120 USD
If not gifting to KNF please add shipping: USA $12.95 / Canada $14.95
q Bronze Ambassador 8 Breast Chek Kits / $240 USD
If not gifting to KNF please add shipping: USA $14.95 / Canada $16.95 / Other $19.95
q Silver Ambassador 12 Breast Chek Kits / $360 USD
If not gifting to KNF please add shipping: USA $16.95 / Canada $19.95 / Other $24.95
q Gold Ambassador 20 Breast Chek Kits / $600 USD
If not gifting to KNF please add shipping: USA $19.95 / Canada $24.95 / Other $29.95
q Platinum Ambassador 50 BCKs / Please call customer service: 480-998-3490, Ext 3
q Pink Ambassador 100+ BCKs / Please call customer service: 480-998-3490, Ext 3

Credit Card Type qVisa qMasterCard qDiscover qAmerican Express

Credit Card Number ___________________________________________

Expiration Date ____/____/____ CVV Code: _______ (3 or 4 Digit Code Credit Card)

__________________________________________________________ ____/____/____
Authorized Payment Signature Date of Signature

THANK YOU for your generous gift and for moving the KNF mission forward!
To pay by check, mail to: (Please make pyable to Plexus Worldwide, Inc.)
Plexus Worldwide, Inc., 7025 E. Greenway Parkway, Suite 250, Scottsdale, AZ 85254You may
want to retain a copy of this document for tax purposes.