Claim Form: Dembo Travel Consultants, Inc. v. PCS International, Ltd.

YOU MUST COMPLETE THIS CLAIM FORM IN ORDER TO RECEIVE ANY BENEFITS. THIS CLAIM FORM MUST BE RECEIVED BY OCTOBER 15, 2007.

Name of owner of facsimile number:

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Address:

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Fax number (including area code):

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Telephone number:

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I submit this Claim Form under penalties of perjury and state that I am (or the business or entity I represent is) the only person or entity entitled to receive the settlement benefit being sought and that I (and/or the business or entity that I represent) had ownership, authority or control over the fax number listed above on or after November 7, 1999. I swear or affirm that I received the above-described facsimile advertisement on or after November 7, 1999 and I do not have an established business relationship with Body Wise International, Inc. or Diane Paulson. I also did not give consent to the sending of the facsimile to me.

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Signature

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Print Name