Circle of Influence  Mastermind Group Application

Please answer the following questions as completely as space allows.

Name	*
Email	*
Phone	*
Mobile
Street Address 1	*
Street Address 2
City	*
State/Province	*
Zip code/postal code	*
Country	*
Choose Mastermind Group Forming Now	*	0421 - Small Business Marketing Mastermind 0502- Blogger Mastermind 0504 - Women in Small Business Mastermind 0510 - Small Business Growth Mastermind
Name of your business. (Blog: Either "none" or the name of your blog, if it is currently active.)	*
How many years have you been self-employed in this business? (Blog: How long have you published your blog?)	*
Are you self-employed full-time or part-time?	*	Full time (40 hours per week). Part time (Less than 40 hours per week). I combine multiple jobs. Blog: N/A
Describe your products or services. (Blog: Topic or "unknown.")	*
If you have employees, how many do you have?
Where do you picture your business (blog) in five years?	*
Rate your commitment to making progress in your business (blog)?	*	4 - Extremely strong commitment. 3 - Strongly committed. 2 - Committed. 1 - Unsure.
Rate your commitment to making progress in your personal life?		4 - Extremely committed. 3 - Strongly committed. 2 - Committed. 1 - Unsure.
How will you make time to participate in the group online discussions?	*
Bloggers: How will you make time to work on improving your blog?
Why should you be chosen to be part of this group? (Convince us that you're the kind of person who doesn't just talk -- they DO something to change things. Convince us that you will be a mastermind group member that others can rely on.)	*
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