Pre Qualification Survey

Complete the Pre Qualification Survey and receive a FREE DiSC� Personal Profile Preview.

Note: All information will be held in the strictest confidence. We will not release your information to a third party without your expressed permission.

Name:
Email:
Title:
Type of Business:
Business/Organization:
Address:
City:
State or Province:
Zip Code:
Country:
Phone:
Fax:

Are you an independent trainer, coach, consultant or speaker, etc. that provides a fee based service to an end user which is a client or customer of yours?
Yes
No
I am currently employed and receive a salary but I will be in the near future

What type of business are you currently in:
Coach
Consultant
Counselor
Educator
Private Professional Practice
Speaker
Starting New Business
Trainer
Other:

*How will you use these products? (Check all that apply)
I will use them as part of my business to assist my clients/customers
I would like to sell the products as a distributor
Other:

*When would you like to become a distributor?
Immediately
1 - 3 months
3 - 6 months
6 - 12 months
Comments:

Thank you for your inquiry.

The Lee Johnson Group
4868 Champlain Court Suite 310
Waldorf, MD 20602
Voice:(301)396-4432
Fax: (301)396-5766
info@leejohnsongroup.com

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