Leadership Development Series Registration – Insert Launch date


Location: Insert name and address of host location

Time: The first workshop is 4-1/2 hours in length: 8:00 a.m. – 12:30 p.m. Remaining workshops are 4 hours: 8:00 a.m. – 12:00 p.m.

Cost: The Series will consist of 12 workshops and 12 one-on-one coaching sessions, to be held once each month for 12 consecutive months. Workbooks and other support materials will be provided for each participant. The Series cost includes a one-time fee of $925.00 USD for the Series materials and $695.00 USD per month for 12 months for the workshops.


Company *


Participant Information


First Name *


Preferred First Name (i.e., Joe vs. Joseph) *


Last Name *


Title *


Company’s Physical Street Address *


City *


State: *   (pull down)



Zip Code *


Email Address *


Confirm Email *

Office Phone *


Cell Phone (for short notice class cancellations, i.e., inclement weather) *



Manager’s Information


Manager’s Name *


Manager’s Title *


Manager’s Phone *


Manager’s Email *


Manager’s Email Confirmation *



Billing Information


Billing Attention *


Billing Address *


Billing City *


State: * (pull down)



Billing Zip *


Additional Billing Information (PO#, separate invoice, etc.)




Invoice Preference *

E-Mail (radio button)

US Mail (radio button)

If Email, please provide Email Address


Confirm Email



A/P Information


Accts Payable Contact *


Accts Payable Phone *


Accts Payable Email


Confirm Accts Payable Email


Preferred Payment Terms *   (pull down – Monthly, Quarterly, One Invoice Payment in Full)




Who Referred You? *


Please click SUBMIT one time and wait until the order is processed. You will receive a confirmation online and via email. Duplicate registrations may occur if you click SUBMIT more than once. Thank you!


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