Consultation Application Entry Form

Thank you for your interest and confidence.

Please complete and submit the following form so I can ensure that I will be able to be of service to you, as explained in the prior page.

Please complete this form so that I can determine whether I would be able to assist you in removing the barriers to achieving your objectives

Name*
First Last
Email*
Enter Email Confirm Email
Phone*
Industry*
Website*
Role or position*
Please enter your role or position in your organization
Key objectives*
Please indicate your 3 key objectives or initiatives for the coming 12 months
Barriers*
Please explain the primary barriers to achieving your objectives or completing your initiaitves
Location*
So that I know roughly what time zone you are in, please select the country (and in the next box, the state if applicable) where you actually work
State/Province*
If you work in the US or Canada, please indicate the state or province
Business Unit Discretionary Budget*
So that I know the scale and complexity of the organization, please enter the annual discretionary budget (i.e not counting salary, rent etc.) of the business unit we may be working with to solve the barrier problems.
Number of Employees in Business Unit*
So that I understand the scale and complexity of the situation, please indicate the number of employees in the business units that are experiencing the barriers we will be working on

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