Healthy Resolutions Management Program Order Form
Shipping Information
Company Name
Name
Address
Phone Number
Email
Product List							Cost	Quantity
Healthy Resolutions Weight Management Program (CD-ROM)							$495
Healthy Resolutions Weight Management Program CD-ROM with Print Version							$545
1 Month Email Counseling for Program Set-Up (retail value $150)							FREE!
					Total Cost:
Payment Method (Please Check One)
Visa
MasterCard
American Express
Check
Money Order
Credit Card Number:  ____________________________________________
Expiration Date : _________________
Card Security Code: ______________
Cardholder Name: ____________________________________________
Cardholder Signature: ____________________________________________
Checks can be made out to Erin Palinski, RD.  PLEASE DO NOT SEND CASH IN THE MAIL. Items will be mailed out upon check clearance. FAX CREDIT CARD ORDERS TO (973) 858-0417.
Mail Order to:
Erin Palinski, RD, LDN
Attn: Healthy Resolutions Weight Management Program
PO Box 122
Hamburg, NJ 07419