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Free Samples Request Form
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You must provide a valid email to receive your samples and information.
Bad e-mail address receive no samples!
Also: "You must be at least 18 years of age to receive anything offered at this site"

First Name   
Last Name 

City  State  Zip
Email Address: "Must Be Valid"
Home Phone Number:

What is your current weight?
What is your desired weight? (in lbs)
Are you sensitive to taking pills? Yes No
About how many 8oz. Glasses of water per day do you drink?
Are you Diabetic? Yes No
Do you have Hypertension or Severe Hypertension?Yes No
Are you on any special type of medication? Yes No
Please list them: Your age?

How did you hear about Be Naturally Fit?

If Search Engine - Which One?
What Search Term or Phrase did you use to find us?

PLEASE NOTE: All the above fields must be
complete before free sample package will be mailed.

Additional comments or special instructions (Alt. shipping, etc.)                       


Information on how to take the Rite-Now Classic Weight Loss will come with your free samples.
Should you have questions, please call:
Cutie Jackson at 1-706-231-8424 or email: sample@benaturallyfit.com . Thanks Kindly.


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