| First Name: |
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| Last Name: |
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| Address 1: |
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| Address 2: |
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| City: |
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| State/Province: |
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| Zip Code: |
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| Email Address: |
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| Verify Email: |
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Sex: |
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Marital Status: |
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| Age: |
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| Date of Birth: |
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| Employment: |
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How did you first discover
that you had been assessed a
charge from MWI or Memberworks?: |
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Explain the means by which
you were charged: |
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List the Bank or Credit card company
that issued card
which was charged.: |
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| Date(s) charge was assessed: |
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| Amount(s) of assessed charges $:: |
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Name of vendor
whose charge appeared
on your credit/debit card: |
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Please explain any information
you have discovered
as to how this charge was levied
against your account: |
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Have you purchased any product over
the telephone, internet, or otherwise
using your credit/debit card
within 60 days of receiving
the charge on your account: |
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If YES what Product did you
purchase?: |
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Have you received any solicitation
by phone or mail at any time within
60 days of being charged by MWI: |
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Did you make a purchase of any
product as a result of the
solicitation by phone or mail.
If YES, what product did you purchase: |
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Have you recently acquired a
new bank or credit card within
60 days of receiving the
unauthorized charge to
your account from MWI: |
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During the sale of product were you
offered a FREE TRIAL Membership
in a buying club
after the purchase
of the origional product: |
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If YES, did you accept or decline the offer
for the FREE TRIAL: |
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If YES, were you made aware
that you were required
to call to cancel
the free trial or
you would be charged: |
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Did you receive any membership
materials from the buy club: |
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If YES, describe the materials you received,
and please fax a copy if possible: |
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At any point did you contact MWI
about the charges you were assessed: |
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If YES, explain what steps you undertook
and the result of your efforts: |
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Have you received any reimbursement
from MWI at any time for
unauthorized charges: |
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If YES, provide dates and
amount of reimbursement: |
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Are you a customer of one of
the following institutions: |
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