Online Application - Todd Durkin : Todd Durkin

Name*

FirstLast

Date

Email*

Phone*

Please give us the best number to reach you at.

Address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Date of Birth*

Company

Website

As part of the Mastermind registration process, please answer the following 6 questions before submitting this form.

If you are new to the Mastermind, please feel free to attach any additional bio sheets, headshots, or support material you deem necessary to help us best understand your background.

IMPORTANT!!

Registration Deadline Date

January 11, 2012

Questions?

Please call Larry Indiviglia or Julie Wilcox at 858-271-1171

What is your current role or job position? (Please be as descriptive as possible).*

What are you most looking to achieve and receive from the Todd Durkin Mastermind Institute?*

What are some of your current obstacles/challenges/issues that you face in your business that you would like resolved as soon as possible?*

What are your business goals in the next 3 years?*

Is there anything else you would like to share as you look to elevate your business and life performance with the Mastermind Institute? *

Please write a short response to the following question: "What does being a fitness professional mean to me?"*

File

The Todd Durkin Mastermind Institute is $99.00 per month and will be billed on the 1st of each month, (Jan 1, Feb 1, etc). OR if would like to pay for the Mastermind for the 2012 year in advance, I would like to extend an additional discount for you: You can pay $997 for the entire year before December 30th, 2011, and receive this “special.” So if you want to save approximately $200.00 for the 2012 year or you want an additional tax write-off for 2011 before the end of the year, NOW is your chance. Simply email me at durkin@fitnessquest10.com and cc. Larry at fitx77@aol.com and we will process this on or before December 30th, 2011.

If you have any questions, you can also call 858.271.1171 and ask for Larry Indiviglia or Julie Wilcox.

Within 5 days of receipt of your completed registration form, you will receive an email confirmation from Larry Indiviglia, Executive Director of the Todd Durkin Mastermind Institute. Additional instructions and access information for the Todd Durkin Mastermind Institute website will be provided after Jan 2, 2012 and before official Institute launch on Jan 11, 2012. You will be placed in the official TD Mastermind Institute Google Groups for official correspondence and to receive special on-going, exclusive emails from Todd. The email you provided above will be used unless informed otherwise via email to Larry Indiviglia at FITX77@aol.com.

Credit Card Type*

Visa
Mastercard
Discover
Amex

Name as it appears on Credit Card*

Credit Card Number

CVS number

Expiration Date

If you were referred to the Todd Durkin Mastermind Institute by another fitness professional or associate, please provide their information below.

Name

Email Address (Optional)

TD Mastermind Institute Registration - 2012