Name* First Last Office PhoneHome/Cell*Email* Enter Email Confirm Email Company NameWebsite1. What is the greatest outcome you’d like to see from your year-long IMPACT Mastermind with Derek?2. What 3 things in your business or life would you change in the next 6 months if you could?3. Who are, or have been your major role models?4. What were your 3 biggest accomplishments in the last two years?5. What is your long-term vision for your life and your business?6. What is your biggest obstacle in reaching your current goals?7. What do you think is responsible for your current results?8. Describe your business as it is right now:9. What are you currently doing to market your business?10. What products/services would you like to introduce in the next 12 months to reach your goals?11. Briefly describe why YOU are a good candidate for Derek’s IMPACT MASTERMIND.12. Anything else we should know when considering you for this program?13) What is your current business or financial condition, and where would you like it to be one year from now?14) Having a list/platform is not required for success in this program, but if you have the following... How many people on your email list?How many Facebook followers?How many Twitter followers?15. Please list your website, if you have one, and any other sites on which you have a presence.16. Why is NOW the right time for you to make this big shift in your life and/or business?NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.