I hereby appoint Emerald Cross as my agent for the sole purpose of procuring substances which I may order for my personal medical use. I made this appointment on  my own free will and acknowledge that no effort has been made by to encourage me to procure or use any product.

I acknowledge that no effort has been made by Emerald Cross to encourage me to procure, purchase or use any substance, nor has any claim been made regarding the usefulness, efficacy, performance, safety or legality of any substance I may acquire through Emerald Cross .

I understand that donations to Emerald Cross, for any medical needs I may acquire through the organization, includes a nominal processing fee to offset expenses, and that this transaction in no way constitutes a commercial promotion.

In consideration of services provided to me by Emerald Cross, I hereby agree, for myself, my heirs and assigns to hold Emerald Cross and anyone acting on their behalf free and harmless from any liability out of my procurement and/or use of any substance which I obtain through Emerald Cross.

Signed: ___________________________________ Date:______________

Name (Printed):________________________________DOB___________

Address: ____________________________________________________

City: _________________________________State:_____ Zip: _________

Phone: _______________________ Cell:___________________________

E-mail: ___________________________________

FAX COMPLETED FORM TO EMERALD CROSS AT: 206-382-7498