Request for Services Form

Mission Statement

The mission of Jim Shipley & Associates, Inc. is to serve as the catalyst for educational improvement by providing services and products that engage educators in a practical approach to using Baldrige Criteria to achieve and sustain performance excellence.

In an effort to serve you better, we ask that you fill out this form completely before submitting. Your request will be processed and you will receive notification confirming/approving your request once a trainer has been assigned. Following JSA's approval of your request, please make any cancellations/changes prior to 60 days before the training in order to avoid cancellation penalties.

PART I: Client Request

Today's Date:

Training Date Requested: *

Expected # of Participants: *

Training Site Location:

Please include the City and State

Suggested Airport:

Service Requested/Special Considerations *

Contact Information:

Contact & Billing Information the Same? *

Yes

No

First Name: *

Last Name: *

Position: *

Organization: *

Address: *

City: *

State: *

Zip: *

Phone: *

Fax:

Alternate Phone:

(Evenings/Weekends/Emergencies)

Email Address: *

PO#:

Billing Information:

First Name *

Last Name *