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              <FONT face="arial" size="3"><B>Print - Fill Out - Mail or, Fax in your order</B></FONT><BR>
              <BR>
              Fax to: <B>1-410-392-7819</B> Or, Mail it to:<BR>
               <B>FMG C/O WeightLossGuide.com</B><BR>
               40 E. Main Street, &nbsp;&nbsp;Dept. #357,<BR>
               Newark, DE 19711 &nbsp;&nbsp;<b>(For fast delivery </b> <a href="" onclick="javascript:history.go(-1); return false;" class="smallc"> 
               <b><u>Click Here</u></a> to return to previous page. Click the "Add To Cart" button).</A></b></TD>
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          <TR><TD><FONT face="arial" size="-1">Name:</FONT></td><td> _________________________       </td></tr>
          <TR><TD><FONT face="arial" size="-1">Email:</FONT></td><td> _________________________</td></tr>
          <TR><TD><FONT face="arial" size="-1">Address:</FONT></td><td> _________________________</td></tr>
          <TR><TD colspan=2><FONT face="arial" size="-2"><B>(Same Day Mailing by US Postal Service - - PO Boxes OK)</B></FONT></td></tr>
          <TR><TD><FONT face="arial" size="-1">City:</FONT></td><td> _________________________</td></tr>
          <TR><TD><FONT face="arial" size="-1">State:</FONT></td><td> _________________________</td></tr>
          <TR><TD><FONT face="arial" size="-1">Country:</FONT></td><td> _________________________</td></tr>
          <TR><TD><FONT face="arial" size="-1">Zip:</FONT></td><td> _________________________</td></tr>
          <TR><TD><FONT face="arial" size="-1">Phone:</FONT></td><td> (____) ______ - ____________</td></tr>
        </table>

       <TABLE border="0" cellpadding="0" cellspacing="10">           
           <TR><TD><FONT face="arial" size="-1"><B>MeltRx™ 24 Ultra:</B></FONT></td><td>_____ @ $54.00</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $39.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>The Ultimate Success Kit:</B></FONT></td><td>_____ @ $$97.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (2-Pack bundle): $84.45 per kit</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Fat Blaster:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Buy 2 Get 1 FREE!</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Hoodoba™ Pure:</B></FONT></td><td>_____ @ $39.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $35.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Hoodoba™ Hunger Block:</B></FONT></td><td>_____ @ $47.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $39.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Hoodoba™ Combo:</B></FONT></td><td>_____ @ $78.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $69.95 per bottle</FONT></td></tr> 
           
           <TR><TD><FONT face="arial" size="-1"><B>NutriMelt Shakes:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Chocolate: Or, (4-Box bargain): $19.95 per box</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>NutriMelt Shakes:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Vanilla: Or, (4-Box bargain): $19.95 per box</FONT></FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Protein Food Bars:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> S'Mores: 1 Box (15 Bars)</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Protein Food Bars:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Raspberry: 1 Box (15 Bars)</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>LipoRidAM:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $23.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>LipoRidPM:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $23.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>TrapRx™ 24 Ultra:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $23.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>PantoSure™:</B></FONT></td><td>_____ @ $15.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $13.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Lift™:</B></FONT></td><td>_____ @ $23.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $19.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Cell-U-Melt:</B></FONT></td><td>_____ @ $23.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $19.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>LipoRidAM:</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $23.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Tonalin CLA (120 ct.):</B></FONT></td><td>_____ @ $29.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $25.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>System I:</B></FONT></td><td>_____ @ $69.95</td><td>= $ __________<FONT face="arial" size="-3"> Drink: Chocolate &nbsp; Vanilla &nbsp; Both</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>System II:</B></FONT></td><td>_____ @ $99.95</td><td>= $ __________<FONT face="arial" size="-3"> Drink: Chocolate &nbsp; Vanilla &nbsp; Both</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>System III:</B></FONT></td><td>_____ @ $179.95</td><td>= $ __________<FONT face="arial" size="-3"> Drink: Chocolate &nbsp; Vanilla &nbsp; Both</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>System Gold:</B></FONT></td><td>_____ @ $249.95</td><td>= $ __________<FONT face="arial" size="-3"> Drink: Chocolate &nbsp; Vanilla &nbsp; Both</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>The Slenderizer:</B></FONT></td><td>_____ @ $39.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $29.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Organic Flax Seed:</B></FONT></td><td>_____ @ $8.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $5.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Organic Flax Seed:</B></FONT></td><td>_____ @ $17.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, (3-Pack bundle): $14.95 per bottle</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Viatril:</B></FONT></td><td>_____ @ $21.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, Buy 2 Get 1 Free</FONT></td></tr>
           <TR><TD><FONT face="arial" size="-1"><B>Viadure:</B></FONT></td><td>_____ @ $21.95</td><td>= $ __________<FONT face="arial" size="-3"> Or, Buy 2 Get 1 Free</FONT></td></tr>
           <TR><TD>&nbsp;</td></tr>
           <TR><TD colspan=2 align="right"><FONT face="arial" size="-1"><b>SUB TOTAL</b></FONT></td><td>= $ __________</td></tr>
           <TR><TD colspan=2 align="right"><FONT face="arial" size="-1"><b>Shipping &amp; Handling</b></FONT></td><td>= $ __________</td></tr>
           <TR><TD colspan=2 align="right"><FONT face="arial" size="-1"><b>TOTAL</b></FONT></td><td>= $ __________</td></tr>
      </table>

        <P><FONT face="arial" size="-1">US: $7.95; $19.95 2-Day Express; $29.95 Next Day Delivery; Canada, Alaska &amp; Hawaii: Ad $10 to US rate; UK, Europe and Austrailia $29.95.</FONT></P>
        <P><FONT face="arial" size="-1">(  ) I am enclosing a check or money order for $____________<BR>
         Please note: If you are paying by check you must make it payable to FMG, LLC<BR>
         and mail it in. We do not accept checks by fax.<BR><BR>
         (  ) I want to charge this purchase to my Credit Card</FONT></P>
        <P><FONT face="arial" size="-1">Credit Card (check one):</FONT></P>
        <P><FONT face="arial" size="-1"><IMG src="images/check.jpg" height="24" width="29">VISA       <IMG src="images/check.jpg" height="24" width="29">MasterCard      <IMG src="images/check.jpg" height="24" width="29">American Express      <IMG src="images/check.jpg" height="24" width="29">Discover</FONT></P>
        <P><FONT face="arial" size="-1">Card Number: _________________________</FONT></P>
        <P><FONT face="arial" size="-1">Expiry Date: _________        Signature: _________________________</FONT></P>
        <P><FONT face="arial" size="-1">I authorize <I>FMG, LLC</I> to charge $____________ to my credit card for the purchase (and shipment) of the above products.</FONT></P>
        <P><FONT face="arial" size="-1">Note: If you are using a credit card charges will show up on your statement under Strictly Health, LLC which is our parent company. All orders will be shipped within 48 hours of receipt. Orders accompanied by checks will be held until cleared.</FONT></P>
        <P><A href="" onclick="javascript:history.go(-1); return false;"><FONT face="arial" size="3" color="#0080FF">Close this window. Return to previous page.</FONT></A><br><br> <a href="http://www.weightlossguide.com/">Diet Pills - Home</a></font></P>
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