Business Information:
    Name:
    Address:

    Type of Business: NonprofitSmall BusinessNongovernmental Organization (NGO)

    Contact Information:

    Tell us about your organization:
    • We are a nonprofit that provides community services such as
    • We are a small business that provides community services
    • We are a nongovernmental organization that provides international services and work with the United Nations

    What is a pressing challenge that requires an innovative approach by Change Agent leaders?

    Are you willing to work with a Change Agent virtually (online)? YesNo
    If yes, (select all that apply): SkypeAdobe ConnectWebExTelephone and FaxEmail and Phone

    How many hours are you willing to spend per week as a Change Agent:
    1-5 hours10 - 20 hours30-40 hours

    Who is the contact person that will work with the Change Agent?
    I prefer my Change Agent to work: Pro BonoFor small stipend (paid by the nonprofit)Other: relationship and stipend