PLEASE TYPE OR PRINT CLEARLY

Name: _________________________________________________________________

Company: ______________________________________________________________

Web Page:   _____________________________________________________________

Address: ________________________________________________________________

City, State, Zip: __________________________________________________________

Phone: ____________________________    Fax: _______________________________

Email:   ________________________________________________________________
                                                                                                                           

The above registrant, by signing this registration, agrees that:

1. It is understood that the manufacture and resulting product known as "The Arizona AFO®" is the proprietary and intellectual property of Arizona AFO, Inc., as is the trademark "Arizona AFO®” and registrant agrees not to duplicate, and that the consideration for and purpose of the license granted hereby is to protect the property and reputation and standards of Arizona AFO, Inc. without interfering with the availability of the Arizona AFO® to patients wherever located.

2. In consideration of the right to provide the Arizona AFO® to patients, registrant accepts, and Arizona AFO, Inc. grants hereby, a nonexclusive, nontransferable, free license, revocable at any time by Arizona AFO, Inc., to use Arizona AFO, Inc.’s teaching materials to measure / fit patients and make castings in accordance with such teachings, send such castings to Arizona AFO, Inc. for use in the making of an Arizona AFO® and receive such Arizona AFO® for sale/delivery to the patient. It is further understood in connection with this license, that Arizona AFO, Inc. would own such casts and may choose to dispose of such casts at any time.

Dated this _________________ day of ____________________200________________

________________________________________________________________________
Printed and signed name of authorized agent

Please note:
First, make a copy of this for your records. Then, fax the completed form to us, mail the original to us or include it with your first cast shipment.  Please call with any questions.  Thank you.