Nutrition Information Network Form
Essential Fats (EFs), Secrets to Living Long and Well

Please send us your information using one of the following methods:

Print out form, fill information using dark ink, and mail to E. Siguel c/o EssentialFats LLC, P.O. Box 10187, Gaithersburg, MD 20898.
E-mail information to nutrnetw@efafood.com. To e-mail, cut and paste information from this form into your e-mail editor or your word processor. Place an X in the appropriate boxes.

Instructions:
Mark the appropriate boxes or write the information requested.
Use Y = Yes, or N = No, where appropriate.

Address, phone, fax is optional. E-mail essential. If you do not have e-mail, give us your phone, address, fax. Phone preferred in case your e-mail changes (a common situation).

Part I. Yourself [required]
[_] Consumer/patient [_] Physician MD, OD [_] Chiropractor [_] Nutritionist RD, other [_] Clinical care [_] Researcher [_] Other Health Professional (explain) _____________________________	[_] President/ Owner [_] Manager [_] Wholesaler/broker [_] Buyer/ Distributor [_] Sales [_] Manufacturer (explain) _________________________________ [_] Other __________________________
Name (1st, Last):___________________________________________________________ Address:__________________________________________________________________ City:___________________________________ State:________ ZIP: _________________ Country ___________________________________
Phone:(______)-________ - ______________	Fax:(______)-________ - ______________
Email: _____________________________	Web site: ___________________________
Optional (help us send you only relevant information)
Profession (describe) _________________________________________ Title (of job) ________________________________________________
Education: [_]BS/BA [_]Master [_]PhD [_]MD [_]RD [_]DC [_]other_________________
Part II. Your Organization [optional]
Organization Type: [_] Retailer [_] Wholesaler [_] Manufacturer [_] Individual [_] Other ________________
Organization Name:_______________________________________________________ Street Address:___________________________________________________________ City:_________________________________ State:________ ZIP: _________________
Phone:(_____) -_________ - ____________	Fax:(______) -________ - _____________
Email: ______________________________	Web site: ___________________________
Retail volume/ sales per year: [_] Under $25K [_] $25-$200K [_] $200K - $1M [_] > $1M
Length you have been with this company/job: [_] 0-6 m; [_]< 1 yr; [_] > 1 yr
Part III. Areas of Interest (check all applicable)
[_] I want to subscribe to a free electronic newsletter on PUFAs and nutrition (by e-mail).
[_] I want more information on the blood test EFA-SRÔ to diagnose EFA abnormalities.
I am interested in information on these conditions:
[_] Dyslipidemia, low HDL, high Triglycerides	[_] Diabetes
[_] Cardiovascular disease	[_] EFA deficiencies
[_] Inflammatory Bowel Disease, SBS	[_] Epilepsy
[_] Infant/mother nutrition	[_] Cystic fibrosis
[_] Other health condition (list) _______________
I would like to buy/distribute:
[_] Oils, capsules	[_] PUFA rich foods/supplements
[_] Oils, bottled	[_] Other nutritional supplements
I am interested in:
[_] Research	[_] Education
[_] Treating patients	[_] Wholesale sales
[_] Electronic distribution of information	[_] Retail sales
[_] Organizing/sponsoring talks on EFAs	[_] Mail order sales
[_] Working on a web site	[_] Manufacturing
[_] Other (explain)____________________	[_] Selling books about EFAs
[_] Becoming a consultant to patients, helping to diagnose and treat abnormalities of fatty acids (deficiencies, imbalances, etc.).
[_] Working with you to educate consumer and health providers about EFAs.
[_] Helping you market foods rich in EFAs and/or books describing the role of EFAs.
[_] I would like training on essential fats.
[_] Displaying information about my company/services/products in an "electronic virtual mall" on the Internet. Please explain your interests in a separate note.
[_] Listing and describing my healthy foods/products in the "yellow pages" section of Dr. Siguel’s new book "Eat to Live Long and Well, Master the EFs". (contact person: ___________________
Other comments:
I have read, understood, and agree to comply with the warnings, disclaimers, and intellectual property protection (including ©) of Dr. Siguel's website and newsletter. Signature________________________________________ Date _____________________

By reading this web site, you agree to read & comply with the following instructions: (a) all information on this website is copyrighted; see conditions for use and permission to reproduce; and (b) the information in this website is not medical advice, merely a general scientific discussion. See your health professional before undergoing any diet, exercise, or medical program. Warnings & disclaimers. You agree to pay us $300 for each unsolicited communication to sell us unsolicited products/services (by e-mail, mail, phone, etc.). Read details.
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