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This revolutionary medical breakthrough in Liposome Technology utilizes a
transdermal delivery system that results in real fat loss in 24 Hours!
Without surgery, diet or exercise! Results are GURANTEED.
For more information and to read our NEWS RELEASE,. Print this whole page
out from your computer; Complete the Information Request Form below, LEGIBLY,
(It is best to type it); And fax your completed Information Request Form to:
919-933-9484
NON-SURGICAL LIPOSUCTION
INFORMATION REQUEST FORM
NAME________________________________________________________________
COMPANY____________________________________________________________
STREET ADDRESS_____________________________________________________
CITY/STATE/ZIP________________________________________________________
TELEPHONE______________________________ Fax:________________________
E-MAIL ADDRESS______________________________________________________
DATE__________________________________ Our Ref: NSL8/28/98/2FFBK
[ ] INTERESTED IN DISTRIBUTING YOUR PRODUCT. Please send me re-seller
information.
OPTIONAL INFORMATION
(Thank you for taking the time to answer these questions.)
AGE: [ ] 18-24 [ ] 25-34 [ ] 35-44
[ ] 45-54 [ ] 55-64 [ ] 65 & over
[ ] FEMALE [ ] MALE
HOW MANY INCHES WOULD YOU LIKE TO LOSE?
______WAIST ______HIPS _____THIGHS _____UPPER ARMS
HOW MUCH WEIGHT WOULD YOU LIKE TO LOSE?
[ ] Under 10 lbs [ ] 10-20 lbs
[ ] 20-30 lbs [ ] 30-40 lbs [ ] 40-50 lbs
[ ] Over 50 lbs
EXERCISING NOW? [ ] YES [ ] NO
DIETING NOW? [ ] YES [ ] NO
INCOME:
[ ] Under $25,000 [ ] $25,000-$50,000
[ ] $50,000-$75,000 [ ]$75,000-$100,000
[ ] $100,000 & Over
THANK YOU! YOU WILL RECEIVE COMPLETE INFORMATION VIA RETURN EMAIL WITHIN 24
HOURS.