| HOME BASED PROGRAM SURVEY |
| 1. Are you currently employed outside the home? |
| 10. Are you SERIOUS about getting involved in a home based opportunity? |
| 6. Have you ever been self-employed or owned a business? |
| 5. Have you ever been involved in a home based opportunity before? |
| 4. How much money would you like to receive? |
| 3. What are your motivations for looking for a home based program? |
| 2. What is your current occupation? |
| 9. Do you have long distance on your telephone? |
| 8. Do you have a major credit card? |
| 7. Do you have cash to "invest" or "leverage" to begin a new opportunity? |
| 13. Is there ANYTHING holding you back from getting involved in a program / opportunity RIGHT AWAY??? |
| Yes |
| No |
| Yes |
| No |
| Yes |
| No |
| Yes |
| No |
| 11. How soon are you looking to start with a program / opportunity? |
| 12. Are you a Self - Starter or Motivated Person? |
| Yes |
| No |
| Explain: |
| Yes |
| No |
| If the survey shows that you are SERIOUSLY interested in a home based opportunity, and we think you are right for our program, someone will be contacting you within 24-48 hours. |
| PERSONAL INFORMATION |
| STATE OF RESIDENCE |
| BEST TIME TO CALL: |
| PHONE NUMBER |
| EMAIL ADDRESS |
| FIRST NAME |
| LAST NAME |
| **Please be sure this information is complete and accurate.** If there is any information missing, we will not be able to contact you. |
| If outside U.S (Specify) |
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| TIME ZONE |
| ***Please use the "Tab" key to go through the page.*** |
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