Title (Mr., Mrs. Dr.):

      First Name :

      Middle Initial (if any):

      Last Name:

      Suffix (Jr., Sr., 2nd) :

      Street Address:

       Apt. or Suite #:

       City:          State/Province:

       Zip/Postal Code:                             Country:

       E-mail Address:

       Telephone w/Area code: 

       Please select your age: 21 or Younger 22-29 30-39 40-49 50-59 60-69 70+           Sex:    Male      Female

       Occupation:   

       Have you tried other sugar-free dessert products ?    Yes       No

            If Yes, which ones?

       Is this sample for someone on a diabetic diet?            Yes       No

       Is this sample for someone trying to lose weight?       Yes       No

       Which influences you most to try a new sugar-free dessert?  Price Ingredients Appearance

       Where do you usually shop for this type of product?  Supermarket Local Grocery Convenience Store Food Co-op Specialty Food Store Coffee Bar Internet/Mail Order

       Which website informed you about this free offer? 

       Why do you want sugar free cookies? 

       ________________________________________________________________

           Do you have any questions or comments?  Please use the area below.

            Thanks for your request!      Limit ONE per household and/or family

This offer may be withdrawn at any time, or when supplies run out. Fulfillment is based on availability of surplus product, customer qualification and production schedules.