Jim lost over 400 pounds & found a new and positive approach to life.
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Mandy: "I lost 27 pounds and 40 inches, in just 5 = weeks!" 
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Information Request Form


Congratulations on taking the next step to weight-loss and improved health, that you can see and feel in a very short time. If you are serious and ready to lose weight for the last time, consider this your invitation to a better lifestyle! Please be open and forthright with your responses in the following profile so that we can better assist you. One of our associates will contact you as soon as possible. The more information you provide us, the better we are able to design a program to best fit your needs!
*First Name: 
*Last Name:
*Address:
City:
State:              Zip:
Country:
*E-mail:
*Day Phone:
*Evening Phone:
*Best Time to Call:

*How much weight would you like to lose? 
5-10 lbs.  10-20 lbs.  20-40 lbs.
40-60 lbs.  60-100+lbs.

*What is Your Weight?  
*What is Your Goal Weight? 
What is Your Height?
What is Your Age?
*How serious are you about losing weight?  
*What is the particular reason you want to lose weight at this time?
How many times a week do you eat out?

Which program would you like more information on? 
(Every program supplies two meals each day)

Starter: (3 items) Provides 100% daily nutrition and powerful appetite control $1-$2/day

FAST: (5 items) consists of the Starter Program , plus dramatic increase of your nutrient absorption, and fat-burning energy $4/day

FASTER: (7 items) consists of the FAST Program , plus weight-loss while you sleep - creating a 24 hour fat-burning metabolism $6/day

FASTEST: (10 items) consists of the FASTER Program, plus a fat magnet, to let you cheat a little. Something to help break up hardened fat cells, and something to help your body digest and absorb protein. As you noticed in our "Before and After" pictures, these products can produce a firm and tone body for you without exercise. $8/day

All programs have an Unconditional 30 Day Money-Back Guarantee!

Thank you for your responses. Please use the space below for any other information you think would help us to assist you with your weight loss needs. Comments:


After you press "Send This" the computer will pause as it processes the request. Please do not hit the submit button twice as it is normal for the computer to pause while it processes your request for a few seconds. It will then show you a confirmation of your submission in a few moments.     


Julie loses over 100 pounds - "I have finally got my life back!"
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"I feel like a new person!" John loses 30 pounds in 3 months!
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Questions/Comments? Email Us! info@www.dietingtips.com