Mobile *

(###)

###

####

Are you Licensed? *

YES

NO

Office Phone *

(###)

###

####

Are you a Corporate Employee *

Only answer YES if you work at a Corporate Office. If you work for a Branch, please answer NO.

YES

NO

Fairway Anniversary *

MM

DD

YYYY

Have you ever been coached before? *

YES

NO

What level of intensity are you looking for in terms of accountability? *

Please rate 1-5 with 1 being the least intensive and 5 being the most intensive

1

2

3

4

5

Where do you rank yourself in terms of consistent daily discipline? *

1 being the least disciplined and 5 being the most disciplined

1

2

3

4

5

Do you have written goals for your business? *

YES

NO

Your Birthdate: *

You can put 1900 for the year, that's not required.

MM

DD

YYYY

Are you currently married or in long-term partnership? *

YES

NO

I prefer not to answer

Spouse/Significant Other Birthdate:

You can put 1900 for the year, that's not required

MM

DD

YYYY