Personalized Wealth Mentoring With Chuck Danes

Please fill out the short form below and a requested time to contact you between 8:00 am - 6:30 pm North American Eastern Time.

(All coaching/mentoring sessions are subject to availability)

Prescreening Application For Real Freedom
Mentoring/Coaching Program

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Web Site URL

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Home Phone*
Home Phone*

Business Phone*
Business Phone*

What is your primary motivation
for wanting to join us in this experience?

(Please be as specific as possible)*
What is your primary motivation
for wanting to join us in this experience?

(Please be as specific as possible)*

What specific outcome, materially and/or otherwise
do you see yourself achieving should you be selected

(What is your Why?)*
What specific outcome, materially and/or otherwise
do you see yourself achieving should you be selected

(What is your Why?)*

How much time are you willing to commit to
the process of achieving your desired results?*
How much time are you willing to commit to
the process of achieving your desired results?*

What do you perceive your
greatest strengths to be?*
What do you perceive your
greatest strengths to be?*

What do you perceive your
greatest weaknesses to be?*
What do you perceive your
greatest weaknesses to be?*

In What Way Do You Feel Chuck and Loreen
Can Best Serve You In Creating Real Freedom?*
In What Way Do You Feel Chuck and Loreen
Can Best Serve You In Creating Real Freedom?*

	Mindset Coaching
	Processes Coaching
	Both

Do you consider yourself as being open, receptive and willing to follow specific steps and guidance relating to your envisioned outcome? *
Do you consider yourself as being open, receptive and willing to follow specific steps and guidance relating to your envisioned outcome? *

Do you have the immediate availability of financial resources neccessary to move forward without imposing a burden?*
Do you have the immediate availability of financial resources neccessary to move forward without imposing a burden?*

On a scale of 1-10 how self-directed are you?

1 = I achieve my best with someone else showing me step-by-step

10 - I prefer to achieve independently without guidance
or input from others

(Please explain)*
On a scale of 1-10 how self-directed are you?

1 = I achieve my best with someone else showing me step-by-step

10 - I prefer to achieve independently without guidance
or input from others

(Please explain)*

Are you ready to move forward immediately
if accepted into the curriculum?*
Are you ready to move forward immediately
if accepted into the curriculum?*

What is your current occupation?*
What is your current occupation?*

	Business Owner
	Employee
	Retired
	Unemployed
	Other

Do you have consistent access to a computer
and an internet connection?

(Mentoring sessions are held online)*
Do you have consistent access to a computer
and an internet connection?

(Mentoring sessions are held online)*

If Selected In Prescreening What is The Best Day and Time For You To Attend The Live Webinar To Determine Finalists?

A thru D Weekdays - E and F Weekend*
If Selected In Prescreening What is The Best Day and Time For You To Attend The Live Webinar To Determine Finalists?

A thru D Weekdays - E and F Weekend*

	A - 10:00 am - 12:00 pm
	B - 2:00 pm - 4:00 pm
	C - 5:00 pm - 7:00 pm
	D - 8:00 pm - 9:00 pm
	E - 12:00 pm - 2:00 pm
	F - 4:00 pm - 6:00 pm

What is the best way to contact you
should we have additional questions?

ie. home phone, business phone, email*
What is the best way to contact you
should we have additional questions?

ie. home phone, business phone, email*

Do you currently have either Oovoo or Skype
internet communication services?
(If yes enter username)*
Do you currently have either Oovoo or Skype
internet communication services?
(If yes enter username)*

Please enter the word that you see below.