Independent Herbalife Distributor
Training & Support Center

Date


First & Last Name:

Street Address:


Suite or Apartment #:


City:


State:


Zip Code:


Country:


Area Code & Phone Number

(Your area code and phone number must be included!)

Fax Number:


Are you concerned about the environment?
yes   no

Do you use any of the following on a regular basis?
Hair Care                            
Skin Care
Bath Products                  
Sun Care
Body Creme/Lotion        
Fragrance

If you were to purchase personal care products, what would be your main concerns:
Price                                                    
Not tested on animals
Hypoallergenic                                  
Allergy Tested
Natural Ingredients                          
Money-back Guarantee
Environmentally Friendly                  
Simplicity
Latest Technology                            
SPF

Are you interested in appearance?
yes   no

If we could help you with products concerned with all these issues, would you be interested?
Yes   No

Would you be interested in a free product demonstration?
Yes   No

Would you like to obtain a free gift by inviting several guests to a demonstration?
Yes   No

Would you prefer information on safe and effective products being sent to you?
Yes   No

When is the most suitable time to contact or telephone you (day & time)?
Day or night:

Prefer further information to be sent to your home or office (yes or no)?

Is there anyone else you know who would take part in this survey?
Name:
Telephone:
Name:
Telephone:
Name:
Telephone: