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* 1. First Name:

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* 2. Last Name:

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* 3. Shipping Address - Street (no PO Boxes accepted):

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* 4. Shipping Address - Street Line 2 (Optional):

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* 5. City:

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* 6. State/Province:

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* 7. Zipcode:

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* 8. Nation (if other than USA):

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* 9. Cell Phone Number:

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* 10. Email Address:

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* 11. What is your height? (examples: 5'11", or 5 ft 11 in)

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* 12. What is your current weight? (pounds)

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* 13. What would you like to see take place in your health over the next 90 days as a result of following a healthy lifestyle program (please be as specific as possible):

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* 14. What has frustrated you most about diet programs in the past?

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* 15. What concerns you most about trying a new diet program?

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* 16. How much aerobic exercise like walking, jogging, cycling, etc. do you do each week?

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* 17. How much anaerobic exercise (like strength training) do you do each week?

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* 18. How would you describe your current eating habits? (select the answer that best fits you)

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* 19. Please rate your current energy level:

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* 20. Shake Flavor Preference: (This will determine how much of each flavor we'll send to you each month - you'll receive 4 containers total each month. You can change this at any time during the future. Simply let us know of any changes in flavor when you send your monthly progress email to us.)

Now click "Done" below, and you'll be taken to a page that will give you detailed instructions on taking your "Before" pictures and emailing them to us. Once we receive your "Before" pictures, we'll set you up to start the product test and start receiving monthly shipments of Shake the Crave Shake Mix for free! We'll also email you with further details and instructions.

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