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Fat Burner Weight Loss Program Interest Form
To see if this program is right for you, I’d like to ask a few questions.
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* Indicates required question
Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
First Name
*
Your answer
Last Name
Your answer
Phone Number
*
Your answer
How did you hear about us?
*
Your answer
How much weight are you looking to lose or what are your goals?
*
Choose
1-5 lbs.
5-10 lbs.
10-25 lbs.
25-50 lbs.
50-100 lbs.
More than 100 lbs.
What have you tried so far?
*
Your answer
What obstacles might restrict you from succeeding?
*
Your answer
Why do this now?
Your answer
What are your biggest frustrations regarding your health?
*
Your answer
Thank you for your interest in my Fat Burner Weight Loss Program!
After submitting this form, I will review your answers and let you know if it's a good fit. Cheers!
www.fatburnerprogram.com
A copy of your responses will be emailed to the address you provided.
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