Registration Form
Thank you for your purchase of Glo bulb for your aquarium. Your bulb will need to be replaced in 8-12 months, depending on usage, to maximize the effects on your fish and plant and maintain general aquarium benefits. We will remind you via email in 8 months and then follow up 60 days later.
The fields with a red ( * ) are required
  Sign up here for your reminder via email in 8 months and then follow up 60 days later.
  Title :
  First name : *
  Last name : *
  Address :*
  Apartment :
  City :*
  Province :*
  Postal Code :*
  Country : * Canada
  Telephone: * --
  Email : *
  By providing your email address you allow Rolf C. Hagen Inc. to send you exciting offers and free samples of product. Rolf C. Hagen Inc. will never share your email address with other parties.
  Retype your email : *
  Age : *
  Sex : *
  Bulb(s) Purchased : *
  
  Date purchased/ installed :*
dd:  mm:  yy:
  Name of store where bulb was purchased:
  Location of store :
City / Province
  Tank Size (Gallons)       Freshwater   Saltwater   Planted
  Fish types :
  Filter type :
  Which brand of fish food do you use?
  Check box if you want to receive coupons:      
  Do you have any other pets? (please check off one or more):
              Bird(s)    
              Cat(s)    
              Dog(s)    
              Ferret(s)    
              Gerbil(s)    
              Hamster(s)  
              Rabbit(s)    
              Reptile(s)    
              I have a pond  
  Occasionally Hagen will be releasing product and other information. (by Email)
Check box if you would you like to be updated on:
       Newsletter :
       Press release :