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Confidential Application Form

In order to support your commitments and intentions, I need to know more about you. Please complete the following application so that I can better support you.

Name

Business Name

Address

Town, State, Zip

Phone (work)

Phone (home)

Phone (cell)

Best time to contact you

Email (valid email required)

Website

Years in Current Business

Date of Birth

Describe your current business.

Describe 3 major goals or intentions you are working on.

Describe 3 major challenges you are dealing with.

Describe 3 sources of stress that interfere with your ability to live a life of joy and ease.

What spiritual disciplines or practices do you use daily or weekly?

Your Schedule

Number of hours you work during an average week

Number of hours you would prefer to work

Percentage of time you would rank as productive

Number of hours you spend marketing your business

Number of hours you can commit on a weekly basis to in order to learn new practices and disciplines that will support you to actualize your vision

Why do you want to participate in a Personal Mastery Program?

Do you have any questions you would like answered?

My consulting and training programs are based on the principles and practices of personal and
professional transformation and the science of success. I do not provide psychological or therapeutic
counseling. By enrolling in a Personal Mastery Program you agree that you are not currently dealing
with a personal or psychological crisis.

I agree!