PERSONAL CONTACT INFORMATION
Your Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Number
-
Area Code
Phone Number
Where do you live?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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The Bahamas
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Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Canada
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Chad
Chile
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Cote d'Ivoire
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Curacao
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Falkland Islands
Faroe Islands
Fiji
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France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
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Jordan
Kazakhstan
Kenya
Kiribati
North Korea
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Laos
Latvia
Lebanon
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Liberia
Libya
Liechtenstein
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Luxembourg
Macau
Macedonia
Madagascar
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Maldives
Mali
Malta
Marshall Islands
Martinique
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Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
How did you hear about us?
YOUR FINANCIAL PROFILE
We request the following information to ensure that Masterminders do not extend themselves financially to the point of interfering with their ability to get the maximum benefit from the program or hinder the other people's growth. It is very important to be honest in your answers; remember, your application is confidential
What is your current annual income?
Where do you want it to be in the next 12 months?
*
What is the highest annual income you have made? What were you doing when you earned that income?
What is your current level of debt? (not including home)
How do you plan to pay for your Ultimate Life & Business Mastermind?
*
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YOUR GOALS & PERSONAL PROFILE
What type of Mastermind are you interested in?
*
InfluencerMastermind (Coaches/Speakers/Trainers)
Start-Up Business Mastermind (from zero to $5million)
Other
If you selected other, please explain what type of Mastermind you are interested in?
What do you want to accomplish as a result of joining the Ultimate Mastermind?
*
What is your current occupation?
*
Previous occupations:
*
Do you currently own your own business?
*
Yes
No
If yes, what kind of business do you own? Please provide your Website URL and FB Fan Page.
Over the next 12 months the forecasted revenue goal for my business is:
Less than $100,000
Less than $250,000
$250,000 - $499,999
$500,000 - $999,999
$1,000,000 - 4,999,999
$5,000,000+
What services or products do you provide?
What is your relationships status?
Married/Partner
In A Relationship
Single
What is working well in your life?
What is not working well in your life? (Be as honest as you can with this answer)
What Strengths/Talents/Resources do you bring to the Mastermind?
What Strengths/Talents/Resources do you need or lack?
What is your 1 year goal for Happiness?
(You will have the chance to update this before and during the program)
What is your 1 year goal for Health?
(You will have the chance to update this before and during the program)
What is your 1 year goal for Wealth?
(You will have the chance to update this before and during the program)
What else would you like Jim to know?
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