First name
Last name
Address
City
State/province
Zip/postal code
Phone #
Email address

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Gender:

• Male
• Female

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Best time to contact:

• Morning
• Afternoon
• Evening
• Weekend

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Time zone:

• Atlantic
• Eastern
• Central
• Mountain
• Pacific
• Alaskan
• Hawaiian

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Desired income:

• $500 per month
• $1,000 per month
• $2,500 per month
• $5,000 per month
• $10,000 or More!

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Hours to invest:

• 5-10 hours per week
• 11-15 hours per week
• 16-20 hours per week
• 21-30 hours per week
• Full-time

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Reason I am looking:

• Be my own boss
• Financial freedom
• Get rid of debt
• Better quality of life
• More time with family
• Approaching retirement
• Job insecurity
• Quit my job
• Tax savings

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Money to invest:

• $100-$250
• $250-$500
• $500-$750
• $750-$1,000
• $1,000 >

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Interest level:

• Interested
• Very interested
• Ready to get started!