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Note: On October 22, the first five applications received will be awarded a 25% discount on full workshop tuition.

APPLICATION FOR WORKSHOPS AND WEBINARS

Please fill out the application below for the desired workshop or webinar. All information collected will remain confidential. There are no payments collected at the time of application submission.

PERSONAL DATA

Name

First Name

Last Name

Nickname/Preferred

Sex

Male

Female

Date of Birth

YYYY

Country of Citizenship:

Please Select which WORKSHOP you would like to attend:

CONTACT DATA

Preferred Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address:

Preferred Telephone

(###)

###

####

PROFESSIONAL DATA

Current Company:

Title/Position:

How long?

Type of Business:

Previous Company:

Title/Position:

How long?

Type of Business:

University:

Degree (highest level attained):

Please estimate the total number of years of business experience:

Goals/Objectives in attending the 6 Secrets Workshop:

What is your experience in raising capital?

I Agree

By submitting this form, I certify that all the information and accompanying material provided in connection with this application are authentic and accurate. If you are accepted and choose to attend, a $500 enrollment deposit will be required to hold your seat.