APPLICATION First Name* Last Name* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* (please provide an email address that will avoid firewall issues)Current Job Title* Company Name* Company Size (# of Employees)* Public or Private Company?* Time in Role?* Current Job Scope*SelectSenior Individual ContributorManagerManager of other managersOtherIf Other, please explain My manager is ____levels from the CEO/Head of Company/Organization.* What is your long-term vision of success for your career?*What is your immediate 1 – 2-year career goal?*What really inspires you when it comes to your career?*The power of this program comes from both the coaching I provide and the insights and support that you’ll gain from your peers. You have valuable contributions to make to the group’s collective learning. It’s important that you are present for all sessions. Sessions will be held on the following dates: 8/17 5:30 PM EST 8/24 5:30 PM EST 8/31 5:30 PM EST 9/07 5:30 PM EST 9/14 5:30 PM EST 9/21 5:30 PM EST 9/28 5:30 PM EST 10/5 5:30 PM EST Time Commitment* Yes, I commit to attending all 8 one-hour sessions. No, I cannot commit to attending all 8 one-hour sessions. I have a known conflict. Please list any dates you will not be able to attend. I commit to being on time, prepared, and engaged in our sessions, including completion of agreed upon homework and activities.* Yes No Group coaching is most successful when all parties feel safe to reveal their honest feelings, concerns, challenges, and successes. I commit to the confidentiality of all my clients and expect that of all group coaching participants. By applying to this program, you are agreeing to maintain the confidentiality of the group.PhoneThis field is for validation purposes and should be left unchanged.