Nutrition Secrets to Success
Response Form

___Yes, Jim. I would like to buy the Nutrition Secrets to Success audio program. I understand that this program will give me a very thorough understanding of proper nutrition that will maximize my exercise routine and give me lasting health. I also understand that if I order today, you will ship me a FREE fitness/exercise journal (a $15 value) along with the program all for only $37 plus (S&H). If you don't want to pay online, you may also call our 24-Hour Order Line at: 1-800-845-9016 to place your order OR you can FAX this form to 301-309-0051. ___ Enclosed is my check, money order or credit card order for $________ plus $ ________ S&H Charge my (Note: You can use more than one card to complete this order): Discover / Mastercard / Visa / American Express Card Number:____________________________________ Exp. Date:______________ Signature: __________________________________________ Print Name: __________________________________________ Address: __________________________________________ City: _____________________________ State: ___________________________ Zip Code: _______________________ Country: __________________________________ Date of Birth: _____________________________________ Telephone: __________________________________________ Fax Number: __________________________________________ E-Mail: __________________________________________ Or Mail This Form To: Coughlin Fitness & Results, LLC 7602 Coddle Harbor Lane Potomac, MD 20854