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Information Request Form
1
My Results
I love these shakes because they're quick & easy to make. And they fill me up. The healthy teas give me the energy boost I need to make it through those long days.
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2
What is your name?
First Name
Last Name
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3
E-mail
example@example.com
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4
Where do you live?
City & State
City & State
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5
Phone Number
Area Code
Phone Number
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6
What are your health goals?
Lose weight
More energy
Gain weight
Tone up
Gain muscle
Maintain a healthy lifestyle
Postpartum results
I'm currently pregnant
Skin care
Other
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7
Have you tried HerbaLife before?
YES
NO
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8
If "YES, " how long has it been?
Less than 2 years
More than 2 years
I haven't!
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9
What is your budget
$100
$150-200
$200-300
Whatever it takes!
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10
Are you ready to start reaching your goals TODAY?
YES
NO
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11
Are you interested in earning extra income by helping others?
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12
Please let me know any other important information about you.
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