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I promise to participate in two short surveys that will be emailed to me in approximately 5 days and 35 days after receipt of my order. Please answer the following questions honestly.

Yes

Current Weight

Exact Weight*

	Male
	Female

Age

	Under 40 years of Age
	40 – 50 years of Age
	Over 50 years of Age

Height ft

Height Inches

State

Email Address:*

Name (Optional) :

Shopping Basket

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Subtotal	$0.00

Note: All prices in US Dollars