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