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Name
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Name
First Name
Last Name
Email Address
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Why Now?
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If accepted what are you looking to achieve in the next 3 months?
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What are the stories/wounds/pains that have caused you not to live up to your true potential thus far?
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What would your life look like if you cleared and HEALED those pains?
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On a scale from 1-10, how WILLING are to stretch yourself emotionally, spiritually, physically and financially for the sake of your dreams?
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This will not be a cake walk, we will go deep on many levels, and this program is relatively inexpensive but it’s not free.*
1
2
3
4
5
6
7
8
9
10
Are you committed to GIVING and being a team player?
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This is a brotherhood of giving men who understand that the more they serve another the more they serve themselves.
Fuck Yes!
No
Why me as your coach/friend/mentor/instigator?
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Select your approximate monthly income
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$0 - $4,999
$5000 - $9,999
$10,000 - $14,999
$15,000 - $24,999
$25,000 - $49,999
$50,000+
Do you have access to (via credit/borrowing) or have the means to invest in yourself right now?
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Age?
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What is your profession/job/career?
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Where are you from and where do you live?
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Thank you!