Name                    Address     

City/State/Zip       Phone   

E-Mail: 

1. Which one statement best describes your skin personality?

a.  "Age gracefully? No way. I'll fight it with the best visible anti-aging products."

b.  "I love trying the latest. I'm always exploring the newest products in skin care."

c.  "For me, less is best. I want fewer products that takes a minimal amount of time."

d.  "I want a step ny step program that meets the essentials for healthy looking skin."

e.  "I have (dry/oily/blemish-prone) skin. I want products for my special needs."

2.  How do you feel overall as compared to your true age?

a.  10 years younger than my real age

b.  5 years than my real age

c. 10years older than my real age

d.  5 years older than my real age

e.  I feel my real age

3.  On a scale of 1 to 5 (5 being excellent, rate the performance of the cleanser sample you tried

         1.   2.    3.     4.    5.

4. On a scale of 1 to 5 (5 being excellent), rate the performance of the moisturizer  sample you tried

          1.   2.    3.     4.    5.

5. Are interested in purchasing the products that you tired?

           Yes       No 

6. Would you be interested in getting these products at a discount or FREE just for hosting a class

           Yes       No