Print - Fill Out - Mail or, Fax in your order
MONTHLY AUTO SHIP ORDER FORM
Fax to: 1-410-392-7819 Or, Mail it to:
FMG C/O WeightDepot.com
40 E. Main Street, Dept. 357,
Newark, DE 19711
Name: _________________________       Click Here For Non-Auto Ship Form
Email: _________________________
Address: _________________________
(Same Day Mailing by US Postal Service - - PO Boxes OK)
City: _________________________
State: _________________________
Country: _________________________
Zip: _________________________
Phone: (____) ______ - ____________
Lipofuel™:_____ @ $49.95= $ __________
LipoRidAM:_____ @ $24.95= $ __________
LipoRidPM:_____ @ $24.95= $ __________
MeltRx™ 24 Ultra:_____ @ $24.95= $ __________
Lipofuel™:_____ @ $29.95= $ __________
Zone Fat Blaster:_____ @ $21.95= $ __________
TrapRx™ 24 Ultra:_____ @ $19.95= $ __________
PantoSure™:_____ @ $13.95= $ __________
Lift™:_____ @ $19.95= $ __________
Organic Flax Oil:_____ @ $12.95= $ __________
Organic Flax Seed:_____ @ $7.95= $ __________
Flax Seed & Oil Combo:_____ @ $19.95= $ __________
St. John's Wort:_____ @ $12.95= $ __________
Muscle Supplement Pack:_____ @ $98.95= $ __________ Check for Stimulant-Free _____
System I:_____ @ $39.95= $ __________ Drink: Chocolate   Vanilla   Both
System II:_____ @ $59.95= $ __________ Drink: Chocolate   Vanilla   Both
System III:_____ @ $139.95= $ __________ Drink: Chocolate   Vanilla   Both
System Gold:_____ @ $198.95= $ __________ Drink: Chocolate   Vanilla   Both
 
SUB TOTAL= $ __________
Shipping & Handling= $ __________
TOTAL= $ __________

US: $7.95 (up to $75); $9.95 (up to $100); $15.00 (up to $150); $20.00 (up to $200); $25.00 (up to $250); $30.00 ($300 & over); $39.95 2-Day Express; Canada, Alaska & Hawaii: Ad $10 to US rate.

(  ) I am enclosing a check or money order for $____________
Please note: If you are paying by check you must make it payable to Freedom Marketing, LLC
and mail it in. We do not accept checks by fax.

(  ) I want to charge this purchase to my Credit Card

Credit Card (check one):

VISA       MasterCard      American Express      Discover

Card Number: _________________________

Expiry Date: _________        Signature: _________________________

I authorize Freedom Marketing Group/WeightDepot.com to charge $____________ to my credit card for the purchase (and shipment) of the above products.

Note: If you are using a credit card charges will show up on your statement under Freedom Marketing Group which is our parent company. All orders will be shipped within 48 hours of receipt. Orders accompanied by checks will be held until cleared.

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