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The Cusp of Keto Order Form
Custom Diet Type: The CUSP of KETO
Special One-time Offer Price:
$9.95
Credit/Debit Convenience Fe
e:
$3.17
Due Today:
$13.12
First Name
*
Last Name
*
Zip Code
*
Phone Number
*
Email:
*
Verify Email:
*
Sex:
*
Male
Female
Age
*
Height (inches):
*
🛈
Number hours
per week you consistently
perform strength training:
*
🛈
0-1.5 hours
2-4 hours
4.5-8 hours
8.5-12 hours
12+ hours
Number hours
per week you consistently perform cardio
:
*
🛈
0-1.5 hours
2-4 hours
4.5-8 hours
8.5-12 hours
12+ hours
Current body weight (lbs):
*
🛈
Target weight (lbs):
*
🛈
Name on Card
*
Credit Card Type
*
Visa
MasterCard
American Express
Discover
Credit Card Number
*
Expiration Date (mm/yy)
*
Terms and conditions:
By checking the box below, I certify that I am an authorized credit card user for the above referenced credit card. I authorize the charge to my credit card for the amount shown above. I agree to pay the total amount above according to the card issuer agreement. I agree to the Terms of Use found
HERE
.
*
I have read, understand, and agree to the Terms and Conditions. I understand and agree that checking the box above constitutes my electronic signature and is intended to have the same force and effect as a manual signature.