Course Date & Location

* City & Course Date:

September 11, 2008 - Boston, MA October 6, 2008 - Boston, MA November 11, 2008 - Boston, MA December 9, 2008 - Boston, MA September 18, 2008 - Chicago, IL October 16, 2008 - Chicago, IL November 13, 2008 - Chicago, IL December 15, 2008 - Chicago, IL January 22, 2009 - Chicago, IL February 5, 2009 - Chicago, IL March 12, 2009 - Chicago, IL April 9, 2009 - Chicago, IL May 7, 2009 - Chicago, IL June 11, 2009TBD - Chicago, IL July 16, 2009 - Chicago, IL September 17, 2009 - Chicago, IL October 15, 2009 - Chicago, IL November 19, 2009 - Chicago, IL December 10, 2009 - Chicago, IL September 15, 2008 - Houston, TX October 23, 2008 - Houston, TX November 20, 2008 - Houston, TX December 11, 2008 - Houston, TX September 16, 2008 - Philadelphia, PA October 21, 2008 - Philadelphia, PA November 11, 2008 - Philadelphia, PA December 16, 2008 - Philadelphia, PA 30 September, 2008 - London 13 October, 2008 - London 19 November, 2008 - London 15 December, 2008 - London 14 January, 2009 - London October 1, 2008 - Washington, DC October 28, 2008 - Washington, DC November 13, 2008 - Washington, DC December 5, 2008 - Washington, DC January 13, 2009 - Washington, DC February 24, 2009 - Washington, DC March 10, 2009 - Washington, DC April 7, 2009 - Washington, DC May 12, 2009 - Washington, DC June 24, 2009 - Washington, DC July 29, 2009 - Washington, DC September 26, 2008 - San Francisco, CA October 15, 2008 - San Francisco, CA November 20, 2008 - San Francisco, CA December 11, 2008 - San Francisco, CA

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:

* 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

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 Executive Mastery

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?