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Form FI-001: Host Organization Registration
Please complete this form to apply for the FULL INFUSION organizational coaching program. There is no obligation. We will use your responses to prepare for our initial consultation with you and/or members of your team, as well as the preparation of a price quote should you choose to enroll.
If you have already committed to FULL INFLUSION but have not yet registered, you will complete this form to get started.
Your responses to this form will be kept confidential and used only by the Critical Victories team.
ABOUT YOUR TEAM
Name of the team or organization submitting this application:
*
Where is the above team located:
*
In how many facilities or locations is this team located?
*
1 location
2 locations
3 locations
More than 3 locations
Which of the following best describes your organization?
*
Privately owned business
Publicly traded business
Not for profit company
Governmental agency
Business-government partnership
Other
Your website URL:
*
Approximate total number of employees/members of the team listed above:
*
Briefly describe the mission or purpose of your team:
*
Is the above-listed team part of a larger parent organization?
*
Yes
No
If applicable, what is the name of the parent organization?
If applicable, what is the approximate total number of employees/members of the parent organization, including the applicant team?
What is the job title of the highest executive leadership authority having direct oversight of the applicant team?
*
PROGRAM POINT OF CONTACT
Please provide information for a main point of contact with whom we may communicate during our evaluation of this application:
Name
First
Last
Job Title or Position:
*
Email
Phone
###
-
###
-
####
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
ELIGIBILITY CRITERIA
The following responses will help us evaluate your potential fit for our program:
Please describe any circumstances, challenges, or opportunities that inspire your team's interest in making improvements:
As you think about the future of your team, in what ways would you like your future to be differeent or better than what you're experiencing today?
As part of our program, we will assemble and communicate with what's called a "Chain of Commitment" to unify individuals on your team who are committed to both self-improvement and the improvement of your team. These are the individuals with whom we will communicate directly during the program, and who will be eligible for one-on-one private coaching sessions and other learning content. Please estimate the number of people you anticipate being part of this chain:
*
If you are unsure, please make your best estimate. We can change the number during the client intake process.
FULL INFUSION programs typically begin on the first Monday of a month you choose. If we agree to work together, please estimate what month you would like the program to start:
MM/YYYY
This is a subcription-based program; however, we have multiple billing options. Please provide any specific billing/invoicing requirements your organization has that we should know about, including the required use of purchase orders:
Is there anything else we should know about you or your team as we review this application?