GENERAL INFORMATION * denotes required field First Name: * Last Name: * Email * Daytime Phone Number * Nighttime Phone Number Fax Number Delivery Address * Apt. / Ste. Gate Code City * State * - - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code * PROMO CODE or Referral Information Refer your friends and get free meals! Ask us for details! Please tell us how, or from whom, you heard about us: Please indicate a START DATE at least one week from today: * PERSONAL INFORMATION Gender * Male Female Birth Month * - - Choose One - - January February March April May June July August September October November December Birth Day * - - Choose One - - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year * 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Weight (lbs) * Height (feet) * 4 5 6 7 Height (inches) * 1 2 3 4 5 6 7 8 9 10 11 Exercise Level * Sedentary (no exercise) Slight (2-3 times / week) Moderate (3-5 times / week) Very Active (5+ times / week) What is your desired GOAL weight? (lbs.) * How would you like your monthly menu delivered? * Email Hard Copy How would you like your snack(s)? * Nutrition Bar / Replacement Shake Fresh Food Item Is there anything else we should know (ex: allergies, questions, comments) MAILING INFORMATION Please be as specific as possible Mailing Address (if different than delivery address) Zipcode State - - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Apt. / Ste. City Where would you like your meal left? * Front Door Back Door Other If other, please explain where *Meal deliveries are scheduled 3 days per week. A $19.95 minimum order applies for each scheduled delivery. ** Pricing increases for diets that exceed 2000 calories. Please call for details. Please read Lean Lifestyle's Policies here. Policies * By checking here I agree to Lean Lifestyle LLC.'s policies. Name *