Untitled Document

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

WEIGHT WATCHERS AT HOME
PO Box 1328, Auckland, New Zealand.

Phone: 0800 009 009

Or fax your credit card orders to (09) 300 4151.

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?

(   ) Woman's Day

(   ) NZ Women's Weekly

(   ) Weight Watchers Magazine

(   ) Friends/Family Recommendation

(   ) Weight Watchers Letter

(   ) Weight Watchers Meetings ad

(   ) Other

Note: 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).