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To join Weight Watchers At Home, simply print out this form, fill it in and send it to

WEIGHT WATCHERS AT HOME
PO BOX 1961, NORTH SYDNEY, NSW, 2059.

Phone: 1300 363 488

Or fax your credit card orders to (02) 9923 2526.

PLEASE NOTE: There must be someone available at time of delivery to sign confirmation of receipt of order.

NAME: .....................................................................................................................

ADDRESS: ................................................................................................................

...............................................................................................................................

TOWN/CITY:.............................................................................................................

POSTCODE:.................................................................................

EMAIL ADDRESS: ........................................................................

Phone: ( ) ..............................................Age ..........................

Start Weight .............................................Height ......................

Goal Weight: .............................................

NOTE:

Also list any health conditions which could affect your weight loss:

.................................................................................................

Signature:..................................................................................

Cardholder's Name .....................................................................

( ) Visa ( ) Mastercard

No. __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiry date: ______\______\______

I wish to purchase the At Home Kit: (Incl. 12 weeks program material + support)

I prefer to pay for the 12 week package as follows:

(   ) I enclose my cheque/money order for the full amount of $297 (plus $9.95 courier)

(   ) Please charge my credit card for the full amount of $297 (plus $9.95 courier)

(   ) Easy payment plan. Please charge my credit card $99 as the first payment upon dispatch and I authorize a further two interest free payments of $99 for the following two months. (plus $9.95 courier)

(all prices include GST)

Total $......................

Please allow 10 days for delivery.

Where did you hear about At Home?

(   ) Sydney Sun Herald

(   ) Brisbane Sunday Mail

(   ) Weight Watchers Magazine

(   ) Friends/Family Recommendation

(   ) Weight Watchers Letter

(   ) Weight Watchers Meetings ad

( ) New Idea

( ) TV Guide Sydney Sun Herald

( ) Melbourne Herald Sun

( ) Woman’s Day

( ) Other

*Written permission from a doctor is required if you are breastfeeding, 10 –15 years old, on medication or being treated for a health condition (e.g. diabetes).