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Kangen Application

If you are interested in purchasing a Kangen "genius water" machine with Udo Erasmus, please fill out this application form to see if you are a good fit for a call with one of our GENIUS WATER coaches. 

Please fill out this form and submit it as soon as you can to make the most of this opportunity.  

Start

Question 1 of 8

What is your phone number?

Question 2 of 8

What is the best day and time to call? (Please include time zone)

Question 3 of 8

What city and country do you live in?

Question 4 of 8

What age range are you in? 

A

18-29

B

30-50

C

51-65

D

65+

Question 5 of 8

How often do you exercise per week? 

A

Never

B

Once or Twice

C

3-4

D

5+

Question 6 of 8

How much do you spend per month on your health and well being? 

A

Nothing

B

$50-250

C

$250-500

D

$500-1000

E

$1000+

Question 7 of 8

Do you currently or regularly suffer from any health issues? 

Question 8 of 8

Do you have any pets or children living at home?

Confirm and Submit