It should take a maximum of 15 minutes for you to complete this membership application, but do take as much time as you like.

To provide the greatest value to GASPPO members, we maintain strict eligibility requirements. To be eligible for membership, you must satisfy the criteria, otherwise we'll refund your membership fee.

Please note that all information you provide will be treated confidentially.

By completing this membership application form, you acknowledge that you accept and agree with the following statement below:

“I own a small professional practice and have a minimum of three years experience in running my business. My practice has generated at least $75,000 in revenues, in at least one fiscal year over the last three years. I can verify this information when asked to. I understand that if GASPPO finds out that the information I have given is not true, then GASPPO will cancel my membership and fully refund my membership fee. If such a situation should occur after a period of 60 days counting from today, then I will not be entitled to a refund. I am a practice owner who:

• Is committed to business and personal growth

• Desires to continuously excel and be balanced in all areas of life

• Is willing to connect, participate and share

• Will keep an open mind with regards to new concepts

• Loves to make a positive impact on peoples' lives

• Demonstrates the utmost personal and professional integrity

• Understands that the membership experience is a process, not a quick fix

I agree to GASPPO's terms and conditions and promise to adhere to, and abide by them.

*All information you provide will be treated confidentially. As our member, it is important to us to provide you with maximum customer service. The information obtained will not be shared in any way and will be used for internal research and customer service only.

ABOUT YOUR PRACTICE/FIRM/COMPANY
*Name of Your Practice/Firm/Company:
*Practice/Firm/Company Address Line #1:
Practice/Firm/Company Address Line #2:
*City/State/Zipcode:
Country:
*Email address:
*Phone Number:
*Year Your Practice/Firm/Company was established:
*Annual Revenue in your last 12-month fiscal year:
*Total Number of People in your team:	0-5 6-10 11-20 21-30 31 and above
*Date of birth (month and year):
*Wedding Anniversary (if applicable):
*Favorite Charity/Philanthropic organization:
*Favorite Cuisine:
*Favorite well-known Role Model:
*What's the BIGGEST challenge you face as a Practice Owner?	Not applicable Need someone to hold me accountable Need more inspiration and/or motivation Need help with time management Need a safe outlet to release my CEO issues Want to work less Want to work smarter
*What's your NUMBER ONE reason for joining GASPPO?	Make more money Build more business relationships Get Advice and/or guidance Other
Imagine that it's now twelve months (one year) from today. What needs to have happened during the next twelve months in order for you to feel happy about your progress, and that of your practice?
Shipping Details (If different from billing information)
Address Line #1:
Address Line #2:
City/Sate/Zipcode:
Country:
Special Delivery Instructions:
*How did you hear about us?	Search engine Printed newsletter or magazine Online newsletter or magazine My colleague A friend Book or ebook Online event In-person event Other
If you chose "other" to answer any question above, please provide further details: