Personal Details

Title:

First Name:

Last Name:

What is Your Wealth Profile:

Select One... Have Not Done a Wealth Profile Creator Star Supporter Deal Maker Trader Accumulator Lord Mechanic

Date of Birth:

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Office Number:

Mobile Number:

Enter your E-mail Address:

Application Questions

Please fill these answers out as accurately as possible

Business Stage:

Select One... Aspiring Entrepreneur Employed Entrepreneur Home Based Entrepreneur Micro Business (1 to 10 Employees) Small Business (11 to 50 Employees) Medium Business (More than 50 Employees)

Company Name:

Describe what your business does in 1 or 2 paragraphs:

Approximate Annual Turnover:

Approximate Net Profit after Tax:

How many Staff do you employ:

How many sales people do you have:

What is your Marketing Budget?:

(Please select) 0 - We dont have a budget Less than R50 000 for year R50k to R100k for year R150k to R250k for year R250 K to R500 K for year R500 to R1mil per year Greater than R1 Million

Please list your major challenges in your business (try list at least 5):

List what you are feeling most stuck with in Sales & marketing or other areas of your business:

What would you like to achieve in terms of growth in 2011 (from what to what). Please explain this in money and number of sales, clients etc:

Please describe what you would like to achieve in the next 3 months:

Please tell us why you wish be considered for the Guide Program:

Please tell us what you would most like to get out of this Entrepreneur Guide Process:

Location

Province:

(Please select) Not in South Africa Gauteng Eastern Cape Freestate KwaZulu Natal Limpopo Mpumalanga Northern Cape North West Western Cape

Country:

AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA ASIA PACIFIC AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOWINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERR. BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS CONGO DRC COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC CZECHOSLOVAKIA (FORMER) DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA EUROPEAN UNION FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRANCE, METROPOLITAN FRENCH POLYNESIA GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREAT BRITAIN GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD & MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKSTAN KENYA KIRIBATI KOREA KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MEXICO MICRONESIA MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT KITTS AND NEVIS SAINT LUCIA SAINT VINCENT SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SPAIN SRI LANKA SUDAN SURINAME SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TOGO TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED STATES UNITED STATES (ISLANDS) URUGUAY UZBEKISTAN VANUATU VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. YEMEN YUGOSLAVIA ZAMBIA ZIMBABWE

Postal Address:

Postal Code:

Physical Address:

Postal Code:

Payment Details

If you are selected, how would you prefer to pay?

If you choose to pay by Credit card we will contact you for your details. If you wish us to debit you, please supply banking details below. Payments must be made in advance and are inclusive of VAT. Invoices will be sent.

Bank Account Name:

Bank Name:

Branch Name:

Branch Code:

Account Number:

Account Type:

Current (Cheque) Savings Transmission