FEEDBACK SHEET

1
Date you attended* This field is required.What date did you attend the BPM?
Month
Day
Year
2
Guest* This field is required.What is your name?
First Name
Last Name
Suffix
3
SpouseWhat is your spouse's name?
First Name
Last Name
Suffix
4
AddressEnter your address
Street Address
Street Address Line 2
City
Please Select
Please Select
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Alaska
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District of Columbia
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Texas
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Virginia
Washington
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State
Zip Code
Please Select
Please Select
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Austria
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The Bahamas
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Belize
Benin
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Brunei
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Chile
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El Salvador
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Eritrea
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Ethiopia
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea-Bissau
Guyana
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
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Lithuania
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Mali
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Mayotte
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Moldova
Monaco
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Montserrat
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Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
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Nigeria
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Northern Mariana
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Poland
Portugal
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Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
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Samoa
San Marino
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Senegal
Serbia
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Sierra Leone
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Slovenia
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eSwatini
Sweden
Switzerland
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Taiwan
Tajikistan
Tanzania
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Isle of Man
US Virgin Islands
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Other
Country
5
Cell Phone Number* This field is required.Enter your cell phone number
6
Email* This field is required.Enter your email address
example@example.com
Confirm Email
7
Who invited you?* This field is required.Select the agent who invited you to the BPM
Select an agent
Select an agent
calljudynow@gmail.com (Judith McCaskill)
warren@warrenrobinson.net (Warren Robinson)
8
Current EmployerWho are you currently employed by?
WE WILL NOT CONTACT YOUR EMPLOYER WITHOUT YOUR PERMISSION
9
The Business* This field is required.I would like to be considered for or know someone that would be a good for:
Become an agent part time (Earn supplemental income and control of time)
Become a Business Owner (Have ownership of a business and freedom)
Get paid for referrals (Earn for referring people to help)
Become a client (I would like a Complimentary Financial Analysis)
Please select one or more positions.
10
Products and Services* This field is required.I would like information or am interested:
Complimentary Financial Roadmap
401(k) Rollover
Income
Life Insurance/Protection for My Family
7702 Plan
Mortgage
Education
Debt
Please select one or more Products.
11
Appointment Type (desired type and day)* This field is required.I would like an appointment on:
Zoom teleconference
Phone
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please select one or more types and days.
12
Appointment Date and Time (desired date and time)* This field is required.I would like an appointment on:
Date
Year
Month
Day
11
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Hour (EST)
58
00
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59
Minutes
PM
AM
PM
13
Applying for an Agent or Business Owner Position (why?)If you want to be considered for a position, why should we contact you?
Huge
Large
Normal
Small
Ok
Ok
14
Applying for an Agent or Business Owner Position (special skills)Select any that apply to you
Bi-Lingual
Sports Background
Military Background
Other Special Skills
15
Referrals/Additional NotesPlease enter the Name, phone number and email of people you want to refer
Huge
Large
Normal
Small
Ok
Ok
16
Please verify that you are human* This field is required.Are you a robot?
Should be Empty: