Independent Herbalife Distributor
Training & Support Center

Date ______  How did you hear about us?_______________________________________
Name, Last___________________ First________________ Spouse________________
Address______________________ City___________ State_____ Zip________________
Hone Phone___________________ Best time to call______________________________
Place of work___________________________ Work phone________________________
Birthdate_____________ Best time to be reached_________________________________
Start weight_____________  Size______ Goal weight____________ Size_____________
What have you tried before___________________________________________________
Why do feel it didn't work____________________________________________________
Are you serious about losing weight now_______  Why______________________________
Do you have any hard to lose areas of cellulite______ Where_________________________

How much of each do you drink daily: Coffee,reg. ______ Decaf______ Soda, diet________ Reg______  Water________ Milk________ Are you lactose intolerant___________ Alcohol________  Do you eat 3 meals a day_______ If no what meals do you skip_______________
What type of foods or snacks do you enjoy_______ (fastfood, fried, carbos, sweets, salty, chocolate)
What part of the day do you snack________ So you excercise__________________
Are you any prescription drugs___________________ If yes, what for________________________
Do you have any dietary restrictions (food or drink)_______________________________________

DO YOU HAVE ANY HEALTH RELATED PROBLEMS?
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____________________________________________________________________________
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WHAT ARE YOUR PERSONAL GOALS?
____________________________________________________________________________
____________________________________________________________________________
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I give discounts or free products for referrals, would this program interest you?________
Would to be interested in hosting a free sample demonstration with your friends in order to earn FREE product? yes____ No____ When______________ where______________

Would you be interested in joining Herbalife:

1. To receive products at a discount?____________
2. A a part-time income around what you are currently doing?(possible extra $500-$1500)__________
3. as a full-time job? (possible extra $1500 - $2500)_______________
4. Or talk to me about these options after I have seen results?__________

Thank you for your cooperation in answering the above questions. This information will be held in strict confidence and will be used only to determine which products to recommend to you.