Name:
Address 1:
Address 2:
Town: , State: , Zip:

Phone:

Plan selection: Micro Plan (25 lbs., 1 day) -- $75.00 Mini-Plan (50 lbs., 3 days) -- $100.00 Regular Plan (75 lbs., 4 days) -- $125.00 Mega Plan (100 lbs., 1 week) -- $135.00 "My God I'm Friggin' Fat" Plan (250 lbs., 1 1/2 weeks) -- $350.00

Order Method: Mastercard Visa Discover

Card Number:
Exp. Date: