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Please be honest on it & fill it out thoroughly.

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Name

Email

Business Website

Where do you live?

Does your business currently make $15,000+ per month in net profit?

Yes No

Do you commit to making a postive impact on the world through your business?

Yes No

Do you want to create freedom in all aspects of your life through your business?

Yes No

Do you consider yourself a cool person who doesn't get bent out of shape easily?

Yes No

Do you value your time above all else?

Yes No

Are you willing and able to invest the necessary resources to hit all of your goals?

Yes No

Do you believe that moving outside of your comfort zone is where your results will occur?

Yes No

Do you see risk taking as the ability to win or the chance to lose?

Ability to win for sure Chance to lose it all

Explain what The Mirror concept means to you.

Why do you want to explore working together?

Tell me something cool about yourself

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