Code Zero Application

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Of Birth *

MM

DD

YYYY

Marital Status *

Married

Married with Children

Divorced

Seperated

Dating

Single

Employment Status *

Employed

Self Employed Entrepreneur

Coaching Programs Completed / Ongoing *

Landmark

Avalon

Tony Robbins

Other

Are You Currently Working With A Coach *

Yes

No

Medical Information *

Are you currently or have you in the past received treatment from one of the following

Psychologist

Psychiatrist

Hypnotherapist

All of the above

None of the above

Plant Medicine *

Do you participate regularly in the following:

Ayahuasca

Mushrooms

Kambo

No

Current Areas In Life You Wish To Address *

Personal Development

Career

Romantic

Financial

Self-Esteem

Confidence

All of the Above

Personal Investment *

Code Zero - The Polarity Process Personal Investment In order to maintain maximum transparency and ethicality , before you choose to move forward, Code Zero prefers that each applicant be aware of their personal investment. A total time of 62 hours will be spent working one on one with Paul Edge over 12 months. A further 8 hours will be spent in a group environment focusing on state-of-the-art sales strategies. The total personal investment for the entire 12 months is only just $12,000. In order to facilitate ease for our clients, a deposit of $4777.00 is requested with 11 monthly subsequent investments of $657.00 Code Zero offers three personal investment options, if you are chosen to be part of the Polarity Process, please indicate which option you prefer.

Investment in Full

Deposit and Monthly

Financing Options