Please complete the form below. Required information is in bold. You will receive a confirmation email with your username and password.  You can choose what information is shown on the public Coach's Report by selecting the appropriate checkboxes.
Personal Information: Show on public page		Company Information: Show on public page
Salutation:	Mr. Mrs. Ms. Dr.	Company name:
First Name:		Department
Last Name:		Job Title:
User Name:		Address:
Password:		Line 2:
Confirm Password:		City:
E-mail:		State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Phone:	(xxx-xxx-xxxx)	Zip:
Fax:	(xxx-xxx-xxxx)	Web site link: If you have a preference on the maximum number of teams that you will allow GLEQ to assign you to coach, please indicate the amount here (please leave the field blank if you do not have a preference): Please provide a short (two or three sentences) summary of your background that we can share with the teams:   If you were referred by a GLEQ Ambassador, please specify their name here:
Address:
Line 2:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Skills and Industry Experience:    Select your skill level from the drop-down, 5 being the highest skill level and 1 being the lowest level. Check all industry experience you may have.  Every skill is not required to have a value selected.
Skills Select Skill Level Marketing   Select 1 2 3 4 5 Finance / Accounting   Select 1 2 3 4 5 Sales   Select 1 2 3 4 5 Operations   Select 1 2 3 4 5 Recruiting / HR   Select 1 2 3 4 5 Strategy   Select 1 2 3 4 5 Grant Writing   Select 1 2 3 4 5 Executive Management   Select 1 2 3 4 5 R&D / Design   Select 1 2 3 4 5 Skill levels: 5 - My expertise 4 - Lots of experience 3 - Average experience 2 - Familiar with topic 1 - Not knowledgeable                         Industry Experience Fund Raising / Venture Capital Services IT / Internet Life Sciences Advanced Manufacturing New Product (industrial or consumer) Alternative Energy Public description:Show on public page Please provide a short (two or three sentences) summary that will be displayed on the Coaches page:   Date You Can Start: