Booking Enquiry Form
Once we receive the filed form, we will contact you shortly to confirm room availability.
Full Name
*
First Name
Last Name
Title/Role (CEO, Operations Manager, Executive Assistant, etc.)
Phone number
*
Do we have your permission to send you text messages regarding updates and upcoming events?
Yes, you may text me for updates and upcoming events.
No, I do not want to recieve any text concerning updates or events.
I only want text messages concerning class updates.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Business name (if you dont already have one selected, write N/A)
Business Year Started
Is your business registered within your state?
Please Select
Yes (continue to next question)
No (skip the next question)
I don’t know
Type of Corporation
Limited Liability Corporation
Nonprofit
General Partnership
S Corporation
Partnership
Other
Mission Statement (Please provide a short overview of business)
What are three specific goals you would like to achieve within the next six months?
How do you envision the Breakers Mentorship Group helping you grow personally and professionally?
May we contact you with appointment updates and reminders?
Please Select
Yes
No
Appointments only
Breakers Mentorship Circle Consultation Appointment
Please verify that you are human
*
Recommended Reading
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Embracing the Cycles of Gratitude
The price of book plus shipping and handling is included. 7-10 day shipping time
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Options
This is the initial payment to begin the program. Change the quantity to pay multiple weeks or pay in full (quantity). Please note that at least one week must be paid.
$
50.00
Quantity
1
2
3
4
5
6
7
8
Item subtotal:
$
0.00
HP Chromebook laptop 13" (renewed)
Valued at $349.99
$
250.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Should be Empty: