Today's Date

First Name

Last Name

Email Address

Phone

Cell Phone

Fax

Company Name

Website URL

Address

City

Zip Code

Country

Assistant Name

Assistant Email

Please describe your current business. Be sure to include how long you have been in business, your major revenue generators and your key successes.

What are your top (3) opportunities?

What are your top (3) challenges in growing your business?

Please tell us the type of products or services you offer. (Feel free to provide additional information.)

What makes your product or service unique? How do you differentiate yourself from your competition?

Where would you like your income to be in the next 12 months?

If you are accepted into this Mastermind Program, what are the top 3 goals that you wish to accomplish in the next 12 months?

What did your business earn in the previous 12 months?

On a scale of 1-10, with 10 being the highest, how committed are you to take your business to the next level?

How do you feel a year-long Mastermind Program would best support you?

Anything else you would like to share with us as we are considering you for the Mastermind Group?