VOMI Executive-In-Residence Application

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Executive-In-Residence ID
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Full Name* This field is required.Your full legal name.
First Name
Last Name
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Your E-mail* This field is required.
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Cell Phone* This field is required.No calls will be placed. For cybersecurity reasons and text messaging of emergency notifications.
Area Code
Phone Number
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Job Title* This field is required.
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Name of Organization* This field is required.
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Organization Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Organization or Institution Website* This field is required.
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Gender* This field is required.
Female
Male
Other
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Is the Member listed above the same as the Authorizing Officer?* This field is required.
Yes
No
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Name of Authorizing Officer* This field is required.
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Title of Authorizing Officer* This field is required.
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E-mail of Authorizing Officer * This field is required.
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Authorizing Officer Certification* This field is required.Put a check mark in this box in order to confirm the authorization information you have just provided.
I hereby certify that the foregoing Authorizing Officer information listed for this order is correct.
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PROGRAM ENROLLMENT INFORMATION
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Select Program Term* This field is required.
30-DAY PROGRAM - USD $15,000.00
90-DAY PROGRAM - USD $45,000.00
180-DAY PROGRAM - USD $90,000.00
1-YEAR PROGRAM - USD $150,000.00
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Why do you want to participate in the VOMI Executive-In-Residence Program?* This field is required.If you need more space and prefer to attach a document, input SEE ATTACHED DOCUMENT in the space provided below and proceed to the next page.
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Submit Your Resume* This field is required.You may submit more than one document and any other document. The size of each document has a limit of 10 MB.
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Select files to upload
Max. file size: 10.0MB
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Your Photo* This field is required.Cybersecurity measure designed to prevent identity fraud and confirm your online identity for videoconferencing purposes. Must be a clearly visible "headshot" photo. NO dark sunglasses, hat, head or face coverings, icons, logos, spouse or friend or girlfriend or children or pets, or scenic places in photo.
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Select files to upload
Max. file size: 20.0MB
Maximum file size - 20 MB
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Are you disabled or mobility impaired?* This field is required.
Yes
No
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Request for Special Accommodations* This field is required.Input N/A in the space provided if you have no need for special and REASONABLE online accommodations.
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Who referred you to us?* This field is required.
A Fellow Executive-In-Residence
A VOMI Executive
An Official Global Ambassador of VOMI Global Think Tank
VOMI Email Promotion
LinkedIn
XING
Google
Yahoo
Bing
Other Search Engine
Word of Mouth
Other
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Payment Form* This field is required.
Send Electronic Invoice
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Electronic Invoice Information: An electronic invoice and copy will be sent to the e-mail address of the Order Requester and the Authorizing Officer along with the VOMI Executive-In-Residence Agreement to be duly executed by the parties. Payment is due immediately upon execution of the VOMI Executive-In-Residence Agreement and in accordance with the terms of the electronic invoice.
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Purchase Order # (Optional)
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Upload copy of purchase order (optional)
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Select files to upload
Max. file size: 10.0MB
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Terms of Agreement

By submitting this form, I agree to the following terms of agreement.
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Let us know you are a real person* This field is required.
Should be Empty:

PROGRAM ENROLLMENT INFORMATION