Licensed Affiliate Application

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Applicant Information

Organization's Name

Organization's Website

Organization's Phone Number (with country code)

Operating Address

City

State/Province

Country

Postal Code

LinkedIn Profile

Number of Total Employees and/or Contractors

Organization's Description

Organization's Purpose/Mission/Vision Statements

Organization Type

For-profitNon-profitOther

Does the organization have offices in multiple regions? If so, please provide the locations.

Please share a link to an introductory YouTube/Vimeo video (if one is available).

Contact Information

Prefix

Suffix

First Name

Last Name

Position Title

Phone Number (please include country code)

Email Address

How did you hear about the Shingo Institute® and its Licensed Affiliates?

Why does the organization want to become a Shingo Licensed Affiliate®?

Does anyone in the organization have a conflict of interest with a current Shingo Licensed Affiliates?

YesNo

If so, please list the Shingo Licensed Affiliate(s) and the reason(s) for the conflict of interest.

550 words remaining

Do you currently have clients that are driving the organization to become a Shingo Licensed Affiliate?

YesNoPotentially

Client References

Please provide the contact information of three clients or customers that the Shingo Institute can contact to discuss the work your organization has done for them.

Reference 1

Name

Phone Number

Organization

Email Address

Reference 2

Name

Phone Number

Organization

Email Address

Reference 3

Name

Phone Number

Organization

Email Address