First Name, Last Name
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Email address to reach you for application
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Best Phone number to reach you about your application
Gender
What is your gender?
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City
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Were you referred by a member? (Indicate Member’s Name)
Highest Level of Education
High School
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Bachelor
Master
PHD
Titles
Administrator
Alternate Administrator
Supervising Nurse
Alternate Supervising Nurse
RN
LVN/LPN
Others (Please Indicate)
Other Title
Agency Name
Type of Agency
*
Home Health
Hospice
Personal Assistance Services
Agency Revenue
*
Under 100,000
100,000-250,000
250,000-500,000
500,000+
What is your greatest challenge in your agency?
*
What area do you desire to improve the most in Homecare Moves to Millions? (Check all applicable)
*
Leadership and Management
Increase Referrals
Networking
Become a Better Leader
Marketing/Branding
Agency Operation
Agency Culture
Team Building
Reaching Your Fullest Potential
Lifestyle Work-Life Balance
Increase Revenue
What do you desire to accomplish in the next 12 months as a member of the Homecare Moves to Millions?
*
How will you be a contribution to the Homecare Moves to Millions as a member?
*
What are your 3 biggest challenges in home care? (Agency Pain Points)
*
What are your strengths and weaknesses as a owner or leader?
*
Agreement *
I understand that Homecare Moves to Millions is NOT personal or business one-one one coaching. I understand that I am not purchasing one-on-one coaching from any consultant or experts associated with Ace Compliance Consulting.
I understand that the Homecare Moves to Millions is administered in a group setting and will not be permitted to speak with the consultant or expert directly one-on-one. I further understand that I will not have access to or be contacting any consultant or experts associated with Ace Compliance Consulting personally outside of the Homecare Moves to Millions related services.
By submitting this application, I attest I have read and agree with all terms and agreements associated with the Homecare Moves to Millions including opting in to SMS, electronic, and email communications.
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