*First Name:

*Last Name:

*Home Phone (with area code):

Work Phone (with area code):

*Email Address:

Fax Number:

*Mailing Address:

*City:

*State:

*Zip Code:

Employer (if applicable):

How did you hear about us?:

Member
Member Name:
Direct Mail
Flyer
Yellow Pages
Television Commercial
Established Corporate Plan
New Corporate Plan
Saw Club Signage
Free Lance-Star
Front Porch
Other
Describe:

Are you a member of a health club now?

Yes  No

If yes, what health club?

What do you do for exercise now?

What is your primary fitness goal?

Additional comments or questions: