APPLICATION to join Chapman Private Practice Alliance
THIS IS DRAFT #4; Jan, 2007.
Please COPY AND PASTE this application into an e-mail or MSWord document.
 Fill in the requested information and e-mail to jkchapman@aol.com
No charges will be applied to your credit card until you've completed an intake interview with 
Jack Chapman and been accepted into the Alliance.

1. PREFERRED METHOD OF CONTACT:

1.a. Name
1.b. Institution/Agency, if any
1.c. Address (street, apt. #, city, state, zip)
1.d. Phone
1.e. E-mail
1.f. Date.

2) Please describe your career situation, include what private practice or career consulting business, if any, you are involved with.

3) Please describe what your goals are for your practice and what would be the most valuable contributions the Private Practice Alliance could make?

4) Who are three people who would vouch for your capability/potential as a private practice career coach?

5) When you see clients privately, what is your fee schedule and structure?

6) EDUCATION & TRAINING:
What education and training do you have that applies to career coaching work.

7) WORK EXPERIENCE
Have you worked as an employee in a career development or in related employment? If yes, please describe.

8) MEMBERSHIPS
Have you been involved in any career-related organizations? If yes, describe here.

9) TIMING. You'll be meeting regularly with peers and facilitators to reach your practice goals. Generally what would be POSSIBLE times and PREFERRED times to meet.
WEEKDAYS
EVENINGS
SATURDAY

10) Please do some creative thinking around “Return On Investment,” or “ROI.” If you bet a dollar and get two dollars back, that's a 100% ROI. Suppose you paid the Charter Membership rate of $250/month. Please describe what increase in your business would get you a 100% ROI. (i.e. $500/month more business)?

11) Here are logistical/financial details of the Chapman Private Practice Alliance.
A) a regular membership is $500 a month.
B) a Charter Member Membership is $250 a month. That rate is locked in for 12 months.
C) Gold Charter Membership is $175/month. That rate is locked in for 12 months.

To qualify for Charter Member, you need to authorize a charge to cover your first month in the Alliance. We won't actually charge your card until we have clear dates that meet your time/scheduling needs to participate. Please include charge information below:

12) Visa/Amex/MC # _________________________________________

Expiration date: __________ Verification # (on back) __________

Billing address & zip : ____________________________

Amount: $175.

GUARANTEE: You will have no money “at risk.” I am so confident that it will meet and exceed your expectations that, if, after 30 days, you're not 100% pleased with your membership in the CPPA, just let me know and we'll refund your complete tuition, no hard feelings, no questions asked. 
GUARANTEE: Even if you're pleased with the training, but simply decided that private practice isn't for you, I guarantee 100% refund, God bless you.

Jack Chapman
jkchapman@aol.com
847.251.4727 (ph)