AM-300 Free Sample Form

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No information will be sold, traded, or given out for any reason - EVER!

You must provide a valid Email to receive your samples.
Bad E-mail's receive no samples! Also: "You must be at least 18 years of age to receive anything offered at this site"
Note: All Fields Required.

First Name

Last Name

Address

City State Zip

Email Address: "Must Be Valid"

Home Phone Number:

What is your current weight?
What is your desired weight? (in lbs)
Are you sensitive to taking pills? Yes No
About how many 8oz. Glasses of water per day do you drink?
Are you Diabetic? Yes No
Do you have Hypertension or Severe Hypertension?Yes No
Are you on any special type of medication? Yes No
Please list them:
Have you received AM300 samples from anyone else? Yes No

How did you hear about AM-300?

If Search Engine - Which One?
What Search Term or Phrase did you use to find us?
Include "Work At Home" Information with samples? Yes No
What is your Age?
PLEASE NOTE: All the above fields must be
complete before free sample package will be mailed.

Additional comments or special instructions (Alt. shipping, ect.)

Information on how to take the AM300 will come with your free samples. Should you have questions, please call:
Linda AT 1-866-632-7255 . Thanks Kindly

| AM300 Home page | Contact Us | AM-300 Real Audio |

Linda Pickle

3400 Old Union Rd

Lufkin, Tx 75904

Phone: 1-866-632-7255

Email: linda@weighless.net

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Important Notice: The information within this web site is not intended to provide medical advice on personal health matters or to guide treatment -- which is only appropriately done by a qualified health professional.
Must be of legal age to shop at this site.
Texas law requires the following warning: This product has ephedrine group alkaloids in the form of herba extracts and may cause serious adverse health effects. Read the label and follow directions