First Name:
Last Name:
Address:
City:
State:
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip:
Country:
Cell:
Phone:
Email:
Fax:
Age:
Male/Female:
Female
Male
Occupation:
Education:
Languages:
Websites:
Please answer the following questions:
1) How did you find out about Dianetics?
2) Have you read the Dianetics website? (www.dianetics.org )
No
Yes
3) What would you most like to improve in your life?
4) What are the biggest problems and difficulties that people have in your country?
5) What interests you about having your own Dianetics Group?
6) Do you have friends or family who need assistance with some area of life?
No
Yes
7) Do you have any friends or family that would not be interested or who might be opposed to your starting a Dianetics Group?
No
Yes
8) Are you the leader of any groups?
No
Yes
If yes, please fill in below:
9) What day or days would be best to have a group meetings each week? (check all that apply)
10) What time would be best?
7:00am
8:00am
9:00am
10:00am
11:00am
12:00pm
1:00pm
2:00pm
3:00pm
4:00pm
5:00pm
6:00pm
7:00pm
8:00pm
9:00pm
10:00pm
11:00pm
12:00am
11) Do you have access to a DVD player?
No
Yes
12) Do you have access to a computer?
No
Yes
13) Do you have a car?
No
Yes
14) Do you have a full time job?
No
Yes
15) Do you speak and read English?
No
Yes
What other languages do you speak?
16) Do you have any friends or family who are influential in your country? (Teachers, Military, Government, Artists, Celebrities)
No
Yes
If yes, please list them and their occupation below:
17) Do you have contacts or friends in the media, newspapers, magazines, TV or radio?
No
Yes
If yes, please list their names, occupation and company:
18) What are your goals in life? What would you like to achieve?
19) What is your education level?
20) Have you ever given lectures, done radio or TV Shows?
No
Yes
21) Are you willing to send a report to us weekly of your activities, successes, etc..?
No
Yes
22) Do you have a camera? Can you email photos of your groups activities and expansion?
No
Yes
23) Do you have a video camera?
No
Yes
24) Why would you be successful in running a Dianetics Group?
25) What are some of your talents and abilities you have?
26) What are your hobbies?
27) Do you have access to a copier?
No
Yes
28) When can you have your first meeting?
29) Do you have staff or helpers for your group?
No
Yes
If yes, please list names and what talents and abilities they have.
30) Do you have any friends or family who would be interested in getting more information or taking the Home Study Course?
No
Yes
If yes, please list their name and email below:
31) Do you have any restrictions or laws forbidding your group from operating, meeting or promoting Dianetics books, seminars etc..?
No
Yes
32) Do you envision any difficulties in getting your group started and expanding?
No
Yes
33) Additional Comments or Concerns:
Please enter the characters displayed above:
