Warranty Registration Card

Please complete the following form in order to activate your five-year guarantee and to receive information about free product upgrades.

Full Name:
Sex:	Male Female
Date of Birth (mm/dd/yyyy):
Type of Diabetes:	Type 1 Type 2
Street Address 1:
Street Address 2:
City:
State:
Zip:
Meter Serial Number (located on back of meter):
Date Purchased (mm/dd/yyyy):
Would you like to receive FIFTY50 product Notifications by email?	Yes No
Email Address: