Name Date of Birth

City Address

Zip State

Home Phone Drivers License Number

Business Phone Type of Package

Social Security Number Store Location

Referred By Add an accelerator

Email Address

Payment Type

Credit Card Number

Expiration Date

What is your skin type?

Do you normally tan in natural light? Yes No

Do you have any allergies to sunlight? Yes No

Have you ever suffered a major sunburn? Yes No

Have you ever been advised by a physician to stay out of the sun? Yes No

If so, for what reason?

Are you taking any medication that may cause sensitivity to sunlight? Yes No

Please be advised that:
(1) Failure to use the eye protection provided to the customer by the tanning faculty may resuly in damage to the eyes.
(2) Overexposure to ultraviolet light causes burns.
(3) Repeated exposure may result in premature aging of the skin and skin cancer.
(4) Abnormal skin sensitivity or burning may be caused by reactions of ultraviolet light to certain:
a: foods, b: cosmetics, or c: medications, including:
i) tranquilizers, ii) diuretics, iii) antibiotics, iv) high blood pressure medications, or v) birth control pills
(5) any person taking a prescription or over-the-counter drug should avoid a tanning device.

I agree to the above information stated within the Super Tan Signup Form.

Please allow up to 24 hours to process your membership request.

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