FEA PROGRAM APPLICATION Spring 2021 Virtual Cohort Starts May 25th, 2021

FEA PROGRAM APPLICATION

Spring 2021 Virtual Cohort
Starts May 25th, 2021

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LEGAL INFORMATION

PRIVACY NOTIFICATION

COLLECTION AND USE: The personal information you provide to us during this application process is collected and used for purposes relating to the Family Enterprise Advisor (FEA) Program.

EXTERNAL STORAGE: This application process is managed using online service providers. By submitting your application, you are consenting to the collection and storage of your information on servers located in the United States.

Please check the box below to continue

I AGREE

PAYMENT OPTIONS | FEA PROGRAM | 2021

*All fees are subject to applicable taxes

*Program fee includes tuition, all reading materials, FEA examination fee and a one-year complimentary membership in Family Enterprise Xchange

Spring 2021 Virtual Cohort – Program Start Date: May 25, 2021

One-Time Payment Option	$15,965*			Grand Total
Payment Due Date	60 Days Prior to Start of Program (Mar 27th, 2021)			$15,965*
Payment Plan Option	1st Installment	2nd Installment	3rd Installment	Grand Total
Payment Due Date Installment Amount	60 Days Prior to Start of Program (Mar 27th, 2020) $5,390*	Aug 16th, 2021 $5,390*	Jan 5th, 2022 $5,390*	$16,170*

Please select your preferred payment option

One-time paymentPayment-Plan Option

PERSONAL DETAILS

Title

First Name (e.g. Robert)

Preferred First Name (name by which you are commonly known by, if different from the above e.g. Rob)

Last Name

Gender

How did you hear about us?

Please list your referral (name of person/organization)

Please list the specific conference/event

Other details

Dietary Restrictions

PROFESSIONAL DETAILS

Current Job Title (enter unemployed if currently not working)

Organization Name (enter Independent if you do not have an organization name)

Portion of Practice Involving Families in Business

Primary Area of Practice (select one choice)

Additional Area of Practice (select one choice)

Website

E-mail

Alternate E-mail

Employer Address Line 1

Employer Address Line 2

Employer Address Line 3

Employer City

Employer Province/State

Employer Postal/Zip Code

Employer Country

Telephone (Please include extension if applicable)

Mobile Phone

BILLING INFORMATION
Please specify how you would like invoices to be made out if different from previous.

Billing Organization Name

Billing Address Line 1

Billing Address Line 2

Billing City

Billing Province/State

Billing Postal Code/Zip Code

Billing Country

E-Mail Address of Billing Contact

Telephone Number of Billing Contact (include extension if applicable)

COURSE MATERIALS
Digital course materials will be available on the FEA Program Moodle website for all participants. Upon request, printed course materials (slide deck and selected class resources) may be provided in a binder.

If you wish to receive a printed binder, please check the box below and complete the shipping information and we will ship you one 2-3 days prior to the start of each module. Please note that Shipping is restricted to within Canada and there is no printed binder for KIA (module 7).

Yes, please ship printed course materials to me at the address below.No, I do not require printed course materials.

Name

Organization Name (if shipping to employer address)

Shipping Address: Line 1

Shipping Address: Line 2

Shipping Address: City

Shipping Address: Province

Shipping Address: Postal Code

Contact Telephone Number

DESIGNATIONS

Please select the number of designations you have

Designation 1

Abbreviation

Full Name of Designation

Conferment Year

Designation 2

Abbreviation

Full Name of Designation

Conferment Year

Designation 3

Abbreviation

Full Name of Designation

Conferment Year

Designation 4

Abbreviation

Full Name of Designation

Conferment Year

Designation 5

Abbreviation

Full Name of Designation

Conferment Year

ADDITIONAL TRAINING OR PROFESSIONAL CERTIFICATIONS

Please select the number of certifications you have

Certification 1

Full Name