Ephedrine Identification Requirements Form

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Sunday: 10:30 am–11:30 pm EST

Regulations regarding Ephedrine-containing products are changing daily. In order that no delays occur on future orders, we are requesting that you complete this form. We believe this information will satisfy all your future requirements.

INSTRUCTIONS: First print this form, then fill in your information and attach your identification. The form must be completed in its entirety. Any missing information will not process your order.

Please Fax this form to us at (415) 404-6082
or Return by Mail to FixFitness, 2017 60th st. Suite # BSMT, Brooklyn, NY 11204
or scan and Email to help@fixfitness.com

 

Name: _______________________________________________________________________________________

Current Address: _______________________________________________________________________________

City: ______________________________________________ State: _____________________ Zip: ____________

Date of Birth: _________ /_________ / _________

Phone Number: ___________________________________________________________
(Phone number must be listed to current address. No business phone numbers.)

Is the phone number listed in your name? Please circle:        Yes          No

If NO, whose name is it listed in, and what relation are they to you: ______________________________________
 

Signature: _____________________________________________        Date: _________ /_________ / _________
                    Signature is mandatory

Driver's License Number: ___________________________________________________

 

 

ONLY One form of identification must be selected from either Class 1 or Class 2
AND a copy must be attached here where indicated.

 
Class 1  

Please attach a copy of your
DRIVER’S LICENSE or STATE ID CARD HERE

Address of Driver’s License/State ID Card
must match current address
No Exceptions


Class 2

Please attach copy of your PERSONAL ID HERE
(other than what you used for Class 1)

For example: Vehicle Registration Card, Passport,
Social Security Card, Voter Registration Card,
or State Identification Card

 

By completing this form you are acknowledging that the information you supplied is correct.