* * * E N T E R 2 W I N * * *

Name:______________________

Address:____________________

City:________________________

Phone:______________________

Email:_______________________

Do you want to lose weight? Yes___ No___

If ‘yes’, how much? ______ lbs.

Do you want more energy? Yes___ No____

Do you have any diet related problems?

Yes___ No___

If ‘yes’ what are they?___________________

Are you interested in making extra$ part time?

Yes___ No __

* * * E N T E R 2 W I N * * *

Name:______________________

Address:____________________

City:________________________

Phone:______________________

Email:_______________________

Do you want to lose weight? Yes___ No___

If ‘yes’, how much? ______ lbs.

Do you want more energy? Yes___ No____

Do you have any diet related problems?

Yes___ No___

If ‘yes’ what are they?___________________

Are you interested in making extra$ part time?

Yes___ No __

* * * E N T E R 2 W I N * * *

Name:______________________

Address:____________________

City:________________________

Phone:______________________

Email:_______________________

Do you want to lose weight? Yes___ No___

If ‘yes’, how much? ______ lbs.

Do you want more energy? Yes___ No____

Do you have any diet related problems?

Yes___ No___

If ‘yes’ what are they?___________________

Are you interested in making extra$ part time?

Yes___ No __

* * * E N T E R 2 W I N * * *

Name:______________________

Address:____________________

City:________________________

Phone:______________________

Email:_______________________

Do you want to lose weight? Yes___ No___

If ‘yes’, how much? ______ lbs.

Do you want more energy? Yes___ No____

Do you have any diet related problems?

Yes___ No___

If ‘yes’ what are they?___________________

Are you interested in making extra$ part time?

Yes___ No __

* * E N T E R 2 W I N * * *

Name:______________________

Address:____________________

City:________________________

Phone:______________________

Email:_______________________

Do you want to lose weight? Yes___ No___

If ‘yes’, how much? ______ lbs.

Do you want more energy? Yes___ No____

Do you have any diet related problems?

Yes___ No___

If ‘yes’ what are they?___________________

Are you interested in making extra$ part time?

Yes___ No __

* * * E N T E R 2 W I N * * *

Name:______________________

Address:____________________

City:________________________

Phone:______________________

Email:_______________________

Do you want to lose weight? Yes___ No___

If ‘yes’, how much? ______ lbs.

Do you want more energy? Yes___ No____

Do you have any diet related problems?

Yes___ No___

If ‘yes’ what are they?___________________

Are you interested in making extra$ part time?

Yes___ No __