EmailMe Form - Form FI-001: Host Organization Registration

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 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?