CHARISMEDX (EMPIRE LEVEL MONTHLY MEMBERSHIP)APPLICATION FORM
This is a long application. We get it. But Charismedx is not for everyone. If you are really interested in joining, please fill out all fields (unless it is specified as optional).
Technical issues with this form?
Email questions@dralexspinoso.com
Basic Information
Name
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First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Instagram (Optional)
Facebook (Optional)
LinkedIn (Optional)
Are you applying through The Charismedx Scholarship Program? (This is only available for a select number of students currently pursuing a medically-related degree (MD, RN, NP, Etc.). If you are a medical entrepreneur or professional, this does not apply to you.)
Please Select
Yes
No
Company Name (Unless Student)
Company Website (Unless Student)
HOW DID WE CONNECT?
We connected because:
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I received a personal invite from Dr. Alex or Vaughn
A current Charismedx member referred me
I was given the invite by a Charismedx Ambassador
I heard about this through a podcast or social media post
Other
If you were given the invite by a current member of Charismedx, please provide the his/her full name:
First Name
Last Name
If you were given the invite by a Charismedx Ambassador, please provide his/her full name and email address:
First Name
Last Name
Email
example@example.com
Financial Information
Annual Gross Revenue
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Goal Net Income
*
All About You
Please tell us about yourself, personally and professionally. Don't overthink it. Tell us what we need to know to understand who you are and what you're about.
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Vision and Plans
Can you share a brief description of your vision and plans for your business and/or professional life?
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Expectations and Goals
Professionally, what do you hope to gain from membership in Charismedx?
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Personally, what do you hope to gain from membership in Charismedx?
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Are there any specific challenges you are hoping to receive help with from Charismedx? (For instance: sales, culture-building, hiring, mental toughness, communication skills training, etc.)
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Strengths and Income Streams
Please share your greatest strengths, both as an entrepreneur and as a person:
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What are the top three revenue streams of your business? (Unless student)
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Core Values
Have you read the Charismedx Core Values as Listed on Website Page?
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Please Select
Yes
No
Which of the core values do you resonate with the most?
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Is there any core value you don't resonate with much? If so, which one is it and why?
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Commitment and Availability
Do you understand that if you are accepted into this mastermind community, we can provide the teaching, training, and guidance, but it is up to YOU to apply and execute?
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Yes, I fully understand this.
Will you do your best to attend 3 in-person meetings a year, generally occurring every quarter? (We understand that unforeseen, non-negotiable life events happen?)
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Yes, I will.
Do you understand that your monthly membership does NOT cover travel, meal, and lodging expenses associated with Charismedx in-person events? (Most of the time, our events will be hosted in Dallas, Texas.)
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Yes, I understand fully
Are you open to happily and generously sharing whatever expertise and experience you have to help fellow Charismedx members?
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Yes, absolutely.
No, not really.
As a Charismedx member, you will have access to unique insight and opportunities to learn. We don't want to give those advantages to just anyone. Would you be willing to sign an NDA form or agreement not to record audio or video of Charismedx training, teaching, events, etc. without express permission from Charismedx?
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Yes, I would be willing.
No, I am not willing.
Final Questions
If you are accepted into Charismedx, do you understand that the cost of the mastermind / community is $3500/month if you pay monthly and $38500 if you choose to pay for one year in advance (getting one month free of charge)?
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Yes, I am an entrepreneur / professional and I understand completely
Yes, I am a student and I understand that scholarship money will be needed to cover the cost of membership
When you join our mastermind, we’ll ask you to sign a simple contract. It’s just there to make sure everyone’s on the same page! It covers: What you’ll get from the mastermind (like mentorship and meetings). Payment details (including due dates, refunds, and cancellations). Ownership of content shared. Rules for creating a safe, respectful group space. A promise to keep certain things confidential. Legal stuff to protect both you and us, just in case. It’s straightforward, and we’ll make sure it’s easy to understand. Do you understand?
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Yes, I understand!
We are taking time thinking through each application, and will almost certainly want to schedule a follow-up conversation with you on Google Meets. Do you understand?
Yes, I understand!
Do you have any final questions or comments? (You may also email questions@dralexspinoso.com)
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By submitting this application, you acknowledge that the information provided is accurate to the best to your knowledge. Submitting this application does not obligate US to approve your application, nor does our approval obligate YOU to join Charismedx.
Name
*
First Name
Last Name
Signature
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Submit
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