Check all of the following that apply: (Be honest- remember, were not concerned with what you've done in the past, but rather want to get an honest feel for where you are today so, if accepted, we can tailor the program to meet your needs.)

No	Some	Yes
			I have written goals for my business for the next three years.
			I have written financial goals for myself and my family for the next three years.
			I have written goals for other areas of my life.
			I have a written plan that guides my actions in business and life, both long term and immediate.
			I have documented marketing systems that consistently and reliably provide a steady stream of new customers.
			I have documented referral systems that optimize referrals from existing customers.
			I have documented management systems that control my business the way I want it.
			I feel that I run my business, it doesn't run me.

Rate the following on a scale from 1-5, according to how much of a challenge they are for you. (1=A big problem for you, 2=Medium Problem, 3=Somewhat of a problem, 4= Rarely, 5= Not a problem at all for you).
	1 2 3 4 5 Generating hot, desirable leads	1 2 3 4 5 Closing sales
	1 2 3 4 5 Building a Flood of Referrals
Structuring Business Systems That:
	1 2 3 4 5 Keep Things Under Control
	1 2 3 4 5 Maximize Profit
	1 2 3 4 5 Let Me Focus on What I Do Best
	1 2 3 4 5 Allow Me To Lead A BALANCED Life And Take As Much Time Off As Id Like.

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Number of hours I work weekly?		Weeks of vacation Ill take this year?
Number of hours Id LIKE to work weekly?		Weeks off Id LIKE to have each year?

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My personal net income in the past 12 months?	Under $50,000 $50,001 - $100,000 $100,001 - $250,000 $250,001 - $500,000 $500,001+
Id like to increase my income in the next 12 months by:	$
If I continue with my business in the direction its going, Ill be financially independent in 3-5 years.	Yes  No

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Answer the following questions using one of the following: Often, Sometimes, Rarely or Never.
 

I feel guilty about not giving enough time to my spouse, children or other relationships in my life.	Often Sometimes Rarely Never
I feel guilty taking time off.	Often Sometimes Rarely Never
I'm very confident in my ability to hire and train new employees.	Often Sometimes Rarely Never

If my schools class reunion was next month, Id feel excited about going. Yes  No

Briefly describe why you feel you're a good candidate for this program.


 

Please Tell Us How To Contact You If You're Accepted Into This Elite Program
Your First Name
Last Name
Agency
Phone
Email
Address
City
State
ZIP

Next Action
	I'm ready to join the Quantum Club. Please have someone contact  me to complete my  membership application.
	I have a few more questions before I decide to join. Please have someone contact me.