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1 forms found in the DOM

POST /successchallenge.htm

<form id="30-day-challenge-form" action="/successchallenge.htm" method="post" role="form">
  <input type="hidden" name="_csrf" value="19XtgAzLllSlvk9LGPAv-fYV0V_PG7s1Xzhr_f5HPazg44L2Xo-jONCMBideuFeqkV6QLv5_7gYWdR-HriVp2A==">
  <!-- start:background -->
  <div class="custom-30-day-challenge-form">
    <div class="background">
      <div class="hidden">
        <h2 class="custom-30-h2 hidden">Tell us about you </h2>
        <small class="custom-30-small hidden">(Your privacy is important to us)</small>
      </div>
      <div class="row">
        <div class="col-md-6">
          <div class="row field-thirtydaychallengeform-first_name required">
            <label class="control-label" for="thirtydaychallengeform-first_name">First Name</label>
            <input type="text" id="thirtydaychallengeform-first_name" class="form-control" name="ThirtyDayChallengeForm[first_name]" aria-required="true">
            <div class="help-block"></div>
          </div>
        </div>
        <div class="col-md-6-right">
          <div class="row field-thirtydaychallengeform-last_name required">
            <label class="control-label" for="thirtydaychallengeform-last_name">Last Name</label>
            <input type="text" id="thirtydaychallengeform-last_name" class="form-control" name="ThirtyDayChallengeForm[last_name]" aria-required="true">
            <div class="help-block"></div>
          </div>
        </div>
      </div>
      <div class="row field-thirtydaychallengeform-email required">
        <label class="control-label" for="thirtydaychallengeform-email">Email</label>
        <input type="text" id="thirtydaychallengeform-email" class="form-control" name="ThirtyDayChallengeForm[email]" aria-required="true">
        <div class="help-block"></div>
      </div>
      <div class="row field-thirtydaychallengeform-mobile_number required">
        <label class="control-label" for="thirtydaychallengeform-mobile_number">Mobile Number</label>
        <input type="text" id="thirtydaychallengeform-mobile_number" class="form-control" name="ThirtyDayChallengeForm[mobile_number]" aria-required="true">
        <div class="help-block"></div>
      </div>
      <div class="row field-thirtydaychallengeform-company required">
        <label class="control-label" for="thirtydaychallengeform-company">Company</label>
        <input type="text" id="thirtydaychallengeform-company" class="form-control" name="ThirtyDayChallengeForm[company]" aria-required="true">
        <div class="help-block"></div>
      </div>
      <div class="row field-thirtydaychallengeform-title required">
        <label class="control-label" for="thirtydaychallengeform-title">Title (CEO, Manager...)</label>
        <input type="text" id="thirtydaychallengeform-title" class="form-control" name="ThirtyDayChallengeForm[title]" aria-required="true">
        <div class="help-block"></div>
      </div>
      <div class="row">
        <div class="col-md-6">
          <div class="row field-thirtydaychallengeform-city required">
            <label class="control-label" for="thirtydaychallengeform-city">City</label>
            <input type="text" id="thirtydaychallengeform-city" class="form-control" name="ThirtyDayChallengeForm[city]" aria-required="true">
            <div class="help-block"></div>
          </div>
        </div>
        <div class="col-md-6-right">
          <div class="row field-thirtydaychallengeform-state required">
            <label class="control-label" for="thirtydaychallengeform-state">State/Country</label>
            <input type="text" id="thirtydaychallengeform-state" class="form-control" name="ThirtyDayChallengeForm[state]" aria-required="true">
            <div class="help-block"></div>
          </div>
        </div>
      </div>
    </div>
    <div class="background">
      <div class="row field-thirtydaychallengeform-how_stress_impacting_life required">
        <label class="control-label">How is stress impacting your life?</label>
        <input type="hidden" name="ThirtyDayChallengeForm[how_stress_impacting_life]" value="">
        <div id="thirtydaychallengeform-how_stress_impacting_life" aria-required="true"><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[how_stress_impacting_life][]" value="Overwhelm"
              class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Overwhelm</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[how_stress_impacting_life][]" value="Frequent Worry"
              class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Frequent Worry</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[how_stress_impacting_life][]" value="Lack of Focus"
              class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Lack of Focus</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[how_stress_impacting_life][]" value="Ongoing Procrastination"
              class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Ongoing Procrastination</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[how_stress_impacting_life][]"
              value="Easily Irritable" class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Easily Irritable</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[how_stress_impacting_life][]"
              value="Anxious or Racing Thoughts" class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Anxious or Racing Thoughts</label><br><label class="ui-checkbox"><input type="checkbox"
              name="ThirtyDayChallengeForm[how_stress_impacting_life][]" value="Low Energy" class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Low Energy</label><br><label class="ui-checkbox"><input type="checkbox"
              name="ThirtyDayChallengeForm[how_stress_impacting_life][]" value="Sleeping Problems" class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Sleeping Problems</label><br><label class="ui-checkbox"><input type="checkbox"
              name="ThirtyDayChallengeForm[how_stress_impacting_life][]" value="Inconsistent Moods" class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Inconsistent Moods</label><br><label class="ui-checkbox"><input type="checkbox"
              name="ThirtyDayChallengeForm[how_stress_impacting_life][]" value="Health Issues" class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Health Issues</label></div>
        <div class="help-block"></div>
      </div>
    </div>
    <div class="background">
      <div class="custom-30-h2"> What would you like to improve? </div>
      <div class="row field-thirtydaychallengeform-what_would_you_improve required">
        <label class="control-label">(Select your top 3)</label>
        <input type="hidden" name="ThirtyDayChallengeForm[what_would_you_improve]" value="">
        <div id="thirtydaychallengeform-what_would_you_improve" aria-required="true"><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Energy" class="ui-helper-hidden-accessible"><span
              class="ui-checkbox"></span> Energy</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Productivity" class="ui-helper-hidden-accessible"><span
              class="ui-checkbox"></span> Productivity</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Leadership" class="ui-helper-hidden-accessible"><span
              class="ui-checkbox"></span> Leadership</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Performance" class="ui-helper-hidden-accessible"><span
              class="ui-checkbox"></span> Performance</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Creativity" class="ui-helper-hidden-accessible"><span
              class="ui-checkbox"></span> Creativity</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Wealth" class="ui-helper-hidden-accessible"><span
              class="ui-checkbox"></span> Wealth</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Prosperity" class="ui-helper-hidden-accessible"><span
              class="ui-checkbox"></span> Prosperity</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Sleep" class="ui-helper-hidden-accessible"><span
              class="ui-checkbox"></span> Sleep</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Mood" class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span>
            Mood</label><br><label class="ui-checkbox"><input type="checkbox" name="ThirtyDayChallengeForm[what_would_you_improve][]" value="Health" class="ui-helper-hidden-accessible"><span class="ui-checkbox"></span> Health</label></div>
        <div class="help-block"></div>
      </div>
    </div>
    <!-- start:submit -->
    <div class="row submit">
      <button type="submit" class="button custom-30-challenge-pull-right">YES, SEE IF I QUALIFY</button>
    </div>
    <!-- end:submit -->
  </div>
</form>

Text Content

SURYA SUCCESS


NAVIGATION






30-DAY CHALLENGE

Congratulations, you’re invited to apply!
Just fill out this short form, to see if you qualify (space is limited).
All the best for 2023!


TELL US ABOUT YOU

(Your privacy is important to us)
First Name

Last Name

Email

Mobile Number

Company

Title (CEO, Manager...)

City

State/Country

How is stress impacting your life?
Overwhelm
Frequent Worry
Lack of Focus
Ongoing Procrastination
Easily Irritable
Anxious or Racing Thoughts
Low Energy
Sleeping Problems
Inconsistent Moods
Health Issues

What would you like to improve?
(Select your top 3)
Energy
Productivity
Leadership
Performance
Creativity
Wealth
Prosperity
Sleep
Mood
Health

YES, SEE IF I QUALIFY
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