ULTIMATUM Application - 1/2022

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ULTIMATUM

The Journey For A New Humanity

January 3-10, 2022 - Denver, Colorado

First TIME ULTIMATUM Participant - Investment $8,888

Application Fee/Deposit Due Today $2,222
Upon approval, your deposit will be applied towards the $8,888 ULTIMATUM experience fee

Returning ULTIMATUM Participant - Investment $7,777

Application Fee/Deposit Due Today $1,111
Upon approval, your deposit will be applied towards the $7,777 ULTIMATUM experience fee

Payment Options

Application Deposit is to be paid by credit card with application
Balance remaining may be paid by credit card, cash, check, money order, or wire transfer
$150 savings if balance is paid by cash, check, money order
$100 savings if balance is paid by wire transfer

Name*

First Name

Last Name

Name you like to be called

Who referred you to ULTIMATUM?

Mobile Phone *

(Please include COUNTRY CODE for international numbers)

Email*

Date of Birth*

Age*

Gender*

Female Male

If your mailing address is different than your billing address on the card you'll be using, please list it here:

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Are you conversational in English? *

Yes No

What is your primary language?*

What other languages are you conversational in?

Are you attending ULTIMATUM with anyone? If so, please describe the relationship, so we may best serve you: *

How did you hear about ULTIMATUM? *

Choose the option that best describes you*

Applicant Not Yet Under Network Care Practice Member D.C. D.C. Spouse Chiropractic Student Chiropractic Assistant Other

Choose all that apply

Have you attended a Donny Epstein EpiExchange experience in the last 2 years*

Yes No

Which EpiEnergetics experiences have you attended?*

Have you EVER been under the care of a Network Practitioner? (To be considered under Network Care: you currently, or have in the past, received Network Spinal Care in an office environment offering Network Spinal Care as a healthcare application for over a month.)*

Yes No

Are you currently in Network Care?*

Yes No

Name of your Network Practitioner*

First Name

Last Name

What length of time have you been in care with this Network doctor?*

One month or less 2 months - 3 months 4 months - 6 months 7 months - 1 year 1 year + 2 years +

Other:

Name of your previous Network Practitioner*

First Name

Last Name

How long has it been since you have been in Network Care?*

How long were you in Network Care before you stopped Care?*

Select Your ULTIMATUM Application Type:*

First Time ULTIMATUM Participant Returning ULTIMATUM Participant

First Time ULTIMATUM Applicant Options

First ULTIMATUM - Investment $8,888 / $2,222 Deposit Charged Today

Returning ULTIMATUM Applicant Options

Returning ULTIMATUM Participant - Investment $7,777 / $1,111 Deposit Charged Today

Upon approval, your $2,222 deposit will be applied towards the ULTIMATUM experience price of $8,888.
The balance of $6,666 is due upon approval of your application.
Your deposit becomes non-refundable once your application is approved.

Upon approval, your $1,111 deposit will be applied towards the ULTIMATUM experience price of $7,777.
The balance of $6,666 is due upon approval of your application.
Your deposit becomes non-refundable once your application is approved.

Please Select Desired Payment Method For Your Balance Due Upon Application Approval*

CREDIT CARD: UPON APPROVAL Please use the credit card used to pay my deposit for the balance of $6,666 CASH: UPON APPROVAL I will pay the balance of $6,516 in cash onsite at event check-in. CHECK/MONEY ORDER: UPON APPROVAL The balance of $6,566 will be paid prior to the event via check or money order. WIRE TRANSFER: UPON APPROVAL A wire transfer for the balance of $6,566 will be sent prior to the event

MAIL CHECK/MONEY ORDER payable to Epstein Institute to the following mailing address:

Epstein Institute, 444 Main Street, Longmont, CO 80501

Please be sure to INCLUDE YOUR NAME and note payment is for ULTUMATUM

WIRE TRANSFER INFORMATION:

Epstein Institute, 444 Main Street, Longmont, CO 80501

Bank Address and Information:
US Bank, 436 Coffman, Longmont, CO 80501

Routing number: 102000021

Account Number: 103685786305

PLEASE INCLUDE YOUR NAME and note payment is for ULTUMATUM

Are You a Seeker?

Please check ALL that apply:*

I want to get more, give more, learn more, experience more, or influence more. I seek a richer, more magical and extraordinary experience for myself and/or others. I ask the BIG questions. I want to/must make a difference in the world. I recognize that there is much more than the physical reality. I am excited by depth of experience and want to play full out in life. I recognize the sacred nature of life and know that there is more to life than circumstances. I have a willingness to go beyond who I am, and what I know, for the promise of MORE. I want to be part of the next shift in consciousness and the human experience.

How many statements above resonate with you?

You are likely discovering that comfort is not always so comfortable.
Often the familiar becomes like a drug, numbing your sense of what is beyond. Although you may want to fit in or make life match your "list," at times, you realize that just changing your circumstance or symptom will produce limited results. As you begin to seek more with curiosity or fascination, you may ask, "Whose life am I living?" You may find that you are less than pleased with the answer. You may be curious about the extraordinary and wonder what it might be like to experience this in some aspect of your life.

The scent of the extraordinary is in the air.

You have sought more and achieved it in at least one area of your life and are looking to bring MORE into another part of your experience. Journeying beyond the ordinary has stimulated your appetite! You know there is more to life than most people accept and are actively seeking MORE. You have tasted victory and are seduced by this feeling. Perhaps you have had MORE in your relationship, and not in your health or your business, or vice versa. You seek to find/discover/unearth/explore, experience, and live more of your authentic signature in the world. You have a hunger to be in community with other seekers.

You are a seeker leader!

A higher-order reality calls you. You know that there is MORE to your life, and you have a hunger to light up the world and make a difference. You have gone where few dare and your tolerance for extraordinary is huge...unprecedented. You seek it and are in awe of it, and you want to shine your authentic signature throughout existence. You recognize that ordinary experiences and strategies for living or business will bring you an ordinary life. Only highly-energized experiences and novel strategies for impactful living can create an extraordinary legacy. You were made for EpiEnergetics and will likely find that it is the missing link in what you have known, learned, intuited, questioned and experienced. Now there is a place to deepen your quest for MORE - a place to come home.

Billing Information

Credit Card Number*

Credit Card Expiration Date*

Month / Year

Credit Card Verification Code*

Name on Credit Card*

First Name

Last Name

Billing Address*

Address Line 1

Address Line 2

City*

State/Province

Zip/Postal*

Country*