1Personal Details2Program Requirements3Short Answers Your Name First Last Company/Organization* Job Role/Title* How many people do you influence at work?Direct InfluenceI.e. direct reports, team membersIndirect InfluenceI.e. coworkers that you regularly connect with, people who report to your direct reports, customers.OtherI.e. small group members, close friends, ministry team.Email* Please enter the email that is associated with your Zoom account.Phone*Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Shirt Size*SMLXLXXLAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Which class are you applying to?*Fall 2023 Young Professionals (Little Rock)Fall 2023 Young Professionals (Northwest Arkansas)How did you hear about the Workmatters Institute?*For example LinkedIn, Boldly, YouVersion, personal reference, etc. (please be specific). Name Email Program Requirements*Participation in the Workmatters Institute requires a significant amount of time and energy. (1.5 hours in class and 1-2 hours of preparation outside of class each week) Are you committed to being prepared each week? Yes No Financial Assistance*Class tuition is $299, due before start of class. Please indicate your specific needs regarding tuition.Please select an optionI plan to pay in full before class begins.I would like to pay in installments.My company has already paid for my spot.I’m not sure.Financial Assistance - More Detail*If yes, please explain. Workmatters will follow up with specific Financial Assistance materials. Please rate your following responses from "Strongly Disagree" to "Strongly Agree."I believe God gave me certain gifts and talents to use for His glory.* Strongly Disagree Slightly Disagree Neutral Slightly Agree Strongly Agree I have a strong desire to grow and take ownership of my personal development.* Strongly Disagree Slightly Disagree Neutral Slightly Agree Strongly Agree I can clearly see how the work that I am doing is serving God or a higher purpose.* Strongly Disagree Slightly Disagree Neutral Slightly Agree Strongly Agree I am willing to take major risks to pursue God’s purposes for me.* Strongly Disagree Slightly Disagree Neutral Slightly Agree Strongly Agree I feel compelled to shape the culture at my workplace.* Strongly Disagree Slightly Disagree Neutral Slightly Agree Strongly Agree PhoneThis field is for validation purposes and should be left unchanged.