Confidential Application for Passion to Profits with Susan Regier Consent(Required) Yes, Sue, I want to join your PASSION TO PROFITS private program so I can receive one-on-one mentoring, guidance, expertise, and advice regarding my business, marketing, Internet presence, products, services, pricing, and more.(Required)Please accept this application as my official indication of interest and let’s talk to ensure this is the right program to help me grow my business (without obligation). Please note that your information is saved on our server as you enter it to assist you with your submission.Name(Required) First Last Company Name Address(Required) Street Address City / Town Province / State Postal Code / Zip Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone(Required)Email Address(Required) Website Please describe your business as it is today (include how long you’ve been in business, your current products and services).(Required)What are you currently doing to market your business?(Required)What 3 successes do you most want to accomplish in the next 12 months?(Required)Who or what do you think is responsible for your current results?(Required)What is your long-term vision for your company – and for you?(Required)What personal and/or business development program(s) have you studied before?(Required)What are the 3 challenges you would like to overcome to achieve your goals?(Required)Are you willing to do what it takes to step out of your comfort zone, eliminate excuses, and be unstoppable toward your own success?(Required) Absolutely Yes Not Sure Anything else you’d like to share when being considered for this program? Payment Procedure Passion to Profits with Susan Regier $4997.00 + HST (where applicable) OPTION 1: I’d like to pay in full and save $500.00! My investment will only be $4497.00 plus HST (where applicable). OPTION 2: I’d like to take advantage of the 4 easy payment plan and complete the program in 4 months. I will make 4 monthly payments of $1250.00 (plus HST where applicable). OPTION 3: I’d like to take advantage of the 6 easy payment plan and complete the program in 6 months. I will make 6 monthly payments of $835.00 (plus HST where applicable). NOTE: Payment available by cheque, e-transfer, or credit card. Please let us know your preferred payment so we can bill accordingly. All fees are non refundable and non cancellable. Payment Option(Required)Select OneOPTION 1: Pay in fullOPTION 2: 4 easy payment planOPTION 3: 6 easy payment planPayment by(Required)Select OneChequee-TransferCredit CardThank you for your application. I will personally review it and contact you within days to let you know if you are approved. To your success, Earnings/Income Disclaimer Confidentiality AgreementThere can be no assurance that any prior successes, or past results, as to income earnings, can be used as an indication of your future success or results. Monetary and income results are based on many factors. We have no way of knowing how well you will do, as we do not know you, your background, your work ethic, or your business skills or practices or risk tolerance. Therefore, we do not guarantee or imply that you will get rich, that you will do as well, or make any money at all. All products and services by our company are for educational and informational purposes only. Use caution and seek the advice of qualified professionals. Check with your accountant, lawyer or professional advisor, before acting on this or any information. Users of our products, services and Web site(s) are advised to do their own due diligence when it comes to making business decisions and all information products and services that have been provided should be independently verified by your own qualified professionals. Our information, products, and services should be carefully considered and evaluated before reaching a business decision, on whether to rely on them. You agree that we are not responsible for the success or failure of your business decisions relating to any information presented by us or our company products or services. The information in this program, written and verbal, is confidential and cannot be duplicated in any form. We respect your confidential and proprietary information, ideas, plans, and trade secrets and must insist that you respect the same rights of Vantage One Writing. Name(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHA