Personalized Wealth Mentoring With Chuck Danes

Please fill out the questionnaire below in it's entirety providing as much detail as possible

(All coaching/mentoring sessions are subject to availability)

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in

Complete the Karatbar Team Prescreening Questionnaire

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

First Name*

Last Name*

E-Mail Address*

Web Site URL

City*

State/Prov*

Zip/Postal Code*

Country*

CountryUnited StatesCanada----------------AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribadiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoFederated States of MicronesiaMoldovaMonacoMongoliaMontserratMoroccoMontenegroMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaS. Georgia and S. Sandwich Isls.Saint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamUS Virgin IslandsWallis and Futuna IslandsWestern SaharaYemenYugoslavia (former)ZaireZambiaZimbabwe

Home Phone*

Business Phone

What is your current occupation?*

How do you see this form of program assisting you individually?*

What are the top 3 reasons for wanting to work with our team?*

Based on where you are now, what do you believe has kept or is keeping you from achieving your individual desires?*

What financial milestones do you intend to reach or exceed as a result of being a part of this project?*

On a scale of 1 - 10 how committed are you to the process of achieving your desired results?*

What do you perceive your 2 greatest strengths to be?*

What do you perceive your 2 greatest weaknesses to be?*

In what way do you feel Chuck and Kristine can best serve you in the attainment of your individual desires?*

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

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 with minimal guidance or input from others (Please explain)*

Are you ready to move forward immediately if selected?*

Do you have immediate availability of the financial resources neccessary to move forward?*

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

Any Additional Comments, Question or Concerns That May Assist Us In Considering Your Application?

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