Get Started TODAY! "*" indicates required fields Application to Change Your LifeMike Stromsoe's Coaching & Mastermind Programs (Must be fully completed to be eligible)Name First Last Cell PhoneEmail Which Coaching Program Level are you interested in? Silver Gold+ Platinum Elite How much money do you want to make in the next twelve months (please specify personal/agency and premium/revenue)? $45,000 or less $45,000 - $75,000 $75,000 - $125,000 $125,000 - $250,000 $250,000 - $500,000 $500,000+ How many hours do you currently work per week? 40+ 30-40 20-30 20-10 10 or less How many hours do you want to work per week? 40+ 30-40 20-30 20-10 10 or less How much time per day do you want to spend with you family and friends? 10 min. 45 min. 2 hours 5 hours How many vacations do you want to take each year? One Two Three Four How many years until you want to retire? 30 years 20 years 10 years 5 years In 3 sentences or less, please describe your current business.If you could wave a magic wand and change 3 things in your business or life right now, what would they be?Describe the 3 major sources of stress and frustration that interfere with your growth and success:Share 3 ways you can contribute to (or help) the other coaching members:Share 3 reasons why YOU would like to be included in Mike's Private VIP Coaching Program:Numbers Don't LieAll progress starts by telling the truth and knowing your destination is all you need to know to get there! Please complete below to the best of your ability at this time.Annual Agency RevenueCurrent12 Month Goal# of Inforce ClientsCurrent12 Month Goal# of Inforce PoliciesCurrent12 Month GoalRetention %Current12 Month Goal# of Annual ReferralsCurrent12 Month Goal# of Full Time EmployeesCurrent12 Month Goal# of Part Time EmployeesCurrent12 Month GoalPercentage of Business: Commercial/Personal/Health/LifeCurrent12 Month GoalPlease let us get to know YOUWe consider our Coaching Program the "UPP Family". Please let us know about any of the following:College and Degree(s): Military Service/Years: Spiritual Affiliation(s): Community Activities: Favorite Charity: Spouse's Name: Important DatesOpened Agency: Birthday: Anniversary: FavoritesKind of food: Beverage: Desserts/Cookies: Type of Music: Favorite Singer/Group: Favorite Color: Hobby: Vacation Place: Favorite Movie: Favorite TV Show: T-shirt size:* Dream Car: Difference MakersWhich book has made a difference in your life? Who is someone you personally admire? What is one "success tip" you can share? How do you make a difference for others? Share something funny (or embarrassing) that you did!NameThis field is for validation purposes and should be left unchanged. You may also download the Application to Change Your Life here. Please email completed application to [email protected] Request a Consultation