Manual Order Form for Certification Registrations AP Survey

Your Contact Information(Required.)

Your First & Last Name

Mailing Address

Mailing Address 2

Mailing City/Town

Mailing State/Province

Mailing Postal Code

Mailing Country

Your Email Address

Your Phone Number

Billing Information(Required.)

Attn:

Company Name

Billing Address

Billing City/Town

Billing State/Region

Billing ZIP/Postal Code

Billing Country

Billing Email Address

Billing Contact Phone Number

LinkedIn Profile URL

Coaching Experience and Certifications(Required.)

Will you be using our products exclusively with leaders in your own organisation?
We need to know if you’ll be using Leadership Circle solely for your own organisation’s leaders or if you plan to offer it outside your organisation.(Required.)

Yes

What Certification do you want to register for?(Required.)

Leadership Circle Profile Certification

Collective Leadership Assessment Certification

Pulse Certification

Leadership System Certification

Other (please specify)

What Certification Date would you like to register for? *

Have you previously completed the Leadership Circle Profile (LCP) 360 assessment? Note: If you have completed an LCP 2 or more years ago, you will complete a new one at no additional cost(Required.)

If you have previously completed a Leadership Circle Profile what email was used?

If you were referred to Leadership Circle, please provide the name and/or email address of the person of your referral:

If you are registering for a Virtual Certification Program, please upload a clear photo of the Participant. The photo will be used for activities in virtual certification.
Photo Guidelines:

Headshot-style image (shoulders and above)
File Name Format: Firstname-LastName
Well-lit and in focus
JPEG or PNG format
Less than 16MB

By uploading your photo, you consent to its storage and use by Leadership Circle for the Certification.

No file chosen

If you are registering for an in person event, please advise if you have any special dietary requirements?

Consent to share details with certification cohort(Required.)

I agree to share my email & phone number with those in my certification cohort

I do not agree to share my email & phone number with those in my certification cohort

By checking this box, you acknowledge that you have read, understood, and agree to the terms of the Practitioner Agreement.

Practitioner Agreement(Required.)

I acknowledge that I have read, understood, and agree to the terms of the Practitioner Agreement.

CANCELLATION & REFUND POLICY
For any transfer requests made with written notice:

45 days prior to the start date of certification, there is no cost.
Within 45 days prior to the start date of certification or for 2nd and subsequent transfers, a fee equivalent to 9% of the workshop fee will be charged.

Cancellations made in writing less than:

4 weeks prior to the start date of certification will receive a refund of 75% of the price paid.
2 weeks prior to the start date of certification will receive a refund of 50% of the price paid.
1 week prior to the start date of certification will receive a refund of 25% of the price paid.

Cancellations made without written notice or a second cancellation will result in no refund.

The Leadership Circle does not apply transfer fees, refunds, or credits towards any program other than the equivalent public certification program listed by Leadership Circle Asia Pacific on its website.

Once you have completed all fields, please click the "Done" button below to submit your registration. For any questions or concerns, please reach out to certification.apac@leadershipcircle.com.