Todd Durkins Mastermind Group Application Platinum & “POWER of 10” Level Basic Information *All fields requiredName* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date* MM DD YYYY Company*Website Social Media Handles*(Facebook, Twitter, Instagram, etc.)TD Mastermind Level that you are applying for*Power of 10PlatinumQuestionnaire Please take as much space as needed to answer the following questions. Please feel free to attach any additional bio sheets, headshots, or support material you deem necessary to help us best understand your background.1. What is your current role or job position?*(Please be as descriptive as possible)2. What are some of your current obstacles/challenges/issues that you face in your business that you would like resolved as soon as possible?*3. What are your business goals in the next 1-3 years?*4. If there is one “GAME CHANGING BUSINESS MOVE” you NEED to make that would make this next year the SINGLE BEST YEAR OF YOUR LIFE, what is it?*5. How can Todd Durkin & the Mastermind BEST help you reach your stated goals? What are you MOST looking forward to receiving from being the Mastermind Group?*6. How can you best contribute to your “teammates” in the Mastermind Group?*7. Are you a member of any other Mastermind Groups? If so, please list:*8. Are you willing to commit to the Platinum or P10 Level for at least on full year?*9. Is there anything else you would like to share as you look to elevate you business an life performance that is important for us to best understand you, your business, life, etc.?*10. How did you find out about the Todd Durkin Mastermind Group? If you were referred by a present TD Mastermind Member (Institute, Platinum, or P10 Level) please provide his/her name.*The Platinum Level Group is $250.00 per month and will be billed at the beginning of the month. The Power of 10 Level Group is $999.00 per month and will be billed at the beginning of the month. If you have any questions, you can also call 858.271.1171 and ask for Larry Indiviglia or Julie Wilcox. Thank you in advance for completing you application. We review all application within 72-hours or receipt and will follow-up with you within 5-business days.