Order Form

ORDER FORM

Name:

E-mail Address:

Address:

Apartment #

City:

State:

Zip Code:

Home Phone:

Work Phone:

Date of Birth: (mm/dd/yyyy)

What are your Weight/Health needs?

Choose your Weight Management Plan:

I want to order the Distributor Pack at a price of $80.00.
(The Distributor Pack includes a full Quickstart Program.)
Yes
No

Please select a Shake Flavor:

What other types of products would you be interested in?
(To select more than one, press the Ctrl key.)

Would you like more information on these and/or other products?
Yes
No

Would you be interested in saving 25% off this purchase, and any future purchases?
Yes
No

Would you be interested in making an extra $500-$1500 a month, part-time, working at home?
Yes
No

Method of Payment:
Check
Money Order

Comments:

An invoice will be e-mailed to you within 48 hours of your order. Orders will be filled upon receipt of payment. You should receive your order within 2-3 weeks. If you would prefer to order by phone, or have any questions, please e-mail us. Sorry, credit card orders not currently available. All information collected from this order form is kept private, and will not be shared with anyone else. We appreciate your patronage.