The Black MasterMind Group Member Application

Email *

First Name *

Last Name *

Address *

City *

State *

Postal code *

Date of birth

Phone *

Who Referred You To The Organization? List Person's Name or Organization Name

Business Information

Business Name

Business Address

Business Address City

Business Address State

Business Address Postal Code

Business Phone Number

Business Email Address

How many full-time employees in your business?

How Many Part-Time Employees?

What business certifications do you have?

Please list Business Name on Facebook, Instagram and LinkedIn

What Is Your Business Legal Structure?

Non-Registered

Sole Proprietorship

LLC

S Corp/C Corp

501C3

Business Trust

Member Information

Why do you want to be a part of this organization?

How Did You Hear About The Organization?

What is your T-Shirt size?

Do You Need Funding For Your Business?

Yes

No

Do You Have A Business Coach?

Yes

No

What area of your business do you need the most assistance?

I Have Been In Business

Less than 3 Years

3-5 Years

5-10 Years

10 + Years

Are You The Business Owner?

Yes

No

Other

What Is Your Highest Level of Educational Attainment?

Some High School

High School Diploma/GED

Some College

Some College Business Courses

Associates Degree

Bachelors Degree

Master's Degree or Higher

Professional Degree (MD, JD, LCSW, etc.)

Doctorate Degree

Collect Payment *

$ 150

*100% secure & safe payments*

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.