Application Form

To start the membership application process, please complete the application form below. After submitting it, you will receive an email with confirmation that your application has been accepted to sign the XIUM9 private association membership agreement. Information on membership fees will also be sent at that time.

PREVIEW THE MEMBERSHIP AGREEMENT HERE

IMPORTANT: Only one submission per person. Please submit a separate form for each member over 18. Our system will have errors if you submit two members at once. Each member MUST also have a unique email address.

Please select a membership option:

Option 1: Canadian Membership (Includes XIUM9 Product)

Option 2: International Membership (Includes XIUM9 Product)

Name

First Name

Last Name

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about XIUM9?

Please provide the name of the person or event.

Why would you like to become a member?

What are your interests and values?

What is your current or most recent profession?

4. How do you feel about your current options to support your best health in Canada?

5. In your own words tell us what confidentiality means to you.

How will you ensure confidentiality is maintained if you become a member?

Select your preferred method of payment:

Online

Transfer

Cash

Cheque

Crypto

Other: Contact me to discuss.

I confirm that:

I am at least 18 years old and that the above information is true.

Application Form

Thank you! Your application is in process and we will contact you once approved.