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. How did you learn of her about the Todd Durkin Mastermind? Did someone refer you?*(Please be as descriptive as possible)2. What is your current role or job position? How long have you been in this role?*3. Tell us about your business: Services, Employees, Revenue Streams, Etc.*4. Which best describes your business right now: Surviving, Struggling, Stability, Succeeding*5. How can the Todd Durkin Mastermind MOST help you right now?*6. Joining a MASTERMIND is also a responsibility. Are you willing to contribute to your team?*7. Have you ever been a part of another mastermind or coaching program? If so, why are you seeking another program?*8. What are your personal or business goals over then next 1-3 years?*9. What is going well in your business or life right now?*10. If there is one "GAME CHANGING MOVE" that you could make in your business or life and FEAR or MONEY wasn't an issue, what would that be?*The Platinum Level Group is $299.00 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.