Subscription Application Form


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Secure Subscription Form

We respect your privacy. The personal information requested below is for use in processing your credit card, which is done with secure encryption. We never reveal or share member information. For complete details see our Privacy Statement.

For international orders or to use PayPal, click the button below:

Customer Information

* = Required - Must match credit card billing address!

First Name [ required ]
Last Name [ required ]
Company
Address Line 1[ required ]
Address Line 2
City [ required ]
State [ US & Canada ]
State/Province [ All other Countries ]
Zip/Postal Code [ required ]
Country [ required ]
Your E-mail Address [ required ]
Phone or Fax Number [ required ]

Shipping Information

Shipping same as billing address

Ship To First Name [ required ]
Ship To Last Name [ required ]
Ship to Company
Ship to Address Line 1[ required ]
Ship to Address Line 2
Ship to City [ required ]
Ship to State [ US & Canada ]
Ship to State/Province [ All other Countries ]
Zip/Postal Code [ required ]
Ship to Country [ required ]

Subscription Options

Subscription Plan:	Diet Coach Cafe offers two levels of membership. Please choose the plan that matches your needs. Success Level Membership: $39 Gives you immediate access to all Cafe resources and learning events. Special VIP Level Membership: $99 per year. In addition to the benefits of the Success Level, the VIP membership includes a 2-session coaching package with Linda Spangle. ($95 value) To make your life as simple as possible, your Diet Coach Cafe membership will automatically renew each year on the anniversary of the date you joined. However, you may cancel at any time.

Choose LOGIN Name [ required ]

Choose PASSWORD [ required ]at least six characters long, using alphas and numbers, no spaces.

Confirm PASSWORD [ required ]

Payment Information

Payment Method [ required ]
Credit Card Number [ required ]
Credit Card Security Code [ required on (MC/Visa/AMEX) ? ]
Expiration Date [ required ]	/
Name on Credit Card [ required ]
Is this a Renewal?
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NOTE: It can take up to a minute to process the credit card information and obtain approval. Please do not press the submit button multiple times - doing so could cause double billing.
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