Course Start Date & Location

* City & Course Date:

September 17, 2008 - Washington, DC September 19, 2008 - Chicago, IL October 16, 2008 - San Francisco, CA October 24, 2008 - Philadelphia, PA January 6, 2009 - Houston, TX January 13, 2009 - London, UK January 22, 2009 - Washington, DC January 23, 2009 - Chicago, IL January 26, 2009 - San Francisco, CA January 27, 2009 - Boston, MA January 23, 2009 - Philadelphia, PA May 7, 2009 - Philadelphia, PA May 20, 2009 - Boston, MA

Personal Information

* First Name:

* Preferred Name:

* Last Name:

Home Phone:

Cellular Phone:

Country Code:

Company Information

* Company Name:

* Street Address:

* City/State/Province:

* Zip/Postal Code:

* Country:

* Work Phone:

Admin. Assistant's Name:

Assistant's Phone:

Assistant's Email Address:

* Your Email Address:

If you are a Business Owner answer the questions below.
If you are an Executive  click here  and proceed to the next section.

When did you start your business?

Why did you start your business?

Annual revenue of your business last year?

10,000,000 or more 5,000,000-10,000,000 1,000,000-5,000,000 500,000-1,000,000 100,000-500,000 Less than 100,000

Annual revenue of your business prior year?

10,000,000 or more 5,000,000-10,000,000 1,000,000-5,000,000 500,000-1,000,000 100,000-500,000 Less than 100,000

Number of employees under your management?

5000 or more 1000 - 5000 100 - 1000 50 - 100 20 - 50 0 - 20

Present title?

Type of business?

What results are you personally accountable for producing?

Executives answer the following.
Business Owners  click here. 

How long at present company?

20 years or more 15 - 20 years 10 - 15 years 5 - 10 years 2 - 5 years 1 - 2 years Less than a year

How long at present position?

20 years or more 15 - 20 years 10 - 15 years 5 - 10 years 2 - 5 years 1 - 2 years Less than a year

Date of most recent promotion?

Present title?

Your manager's name?

Manager's title/position?

What results are you personally accountable for producing?

Educational Background

Undergraduate degree?

Yes   No

Field of study?

College or university?

Graduate degree?

Yes   No

Field of study?

College or university?

Other education/business courses?

Other Gap International programs/courses?
   * To select more than one,
      press and hold the CTRL key

Alignment Intensive Breakthrough Intensive Breakthrough Performance Competencies 2 Day Programs Building a Breakthrough Executive Consulting 1/1 Consulting Executive Challenge Course Executive Mastery Other

Your Participation in the Executive Challenge Course

What is the predictable future that you could project 9-12 months from now?

What breakthrough business results would you like to produce in the course?

What aspect(s) of your leadership would you like to develop more fully out of participating in the course?

For what do you wish to be known in your organization for which you are not already known?

What would you say is the most significant accomplishment of your career?

Is there anything else you would like us to know regarding your participation in the course?