Self-Portrait™ Associate Application

Thank you for your interest in our Self-Portrait™ Assessment Associate Program.

Please read our Associate Agreement before completing this form. By completing this form you consent to the terms of the Associate Agreement.

Name(required)

Company Name (if any)

Make payments out to:(required)

Street Address(required)

City, State, Zip Code if U.S.(required)

Province, Country, Zip Code if not U.S.

Phone Number(required)

Website

Your primary product and/or service

For which assessment do you want the Associate link - choose one or both(required)

Power Traits Assessment for Students Power Traits Assessment for Adults Both Assessments

Are you familiar with our products and/or services?

Yes No

Are you familiar with Self-Portrait™ Assessment for student learning success?

Yes No

Are you familiar with Self-Portrait™ assessment for adult personal success?

Yes No

Comments or other information you want us to know about you.

Email Address(required)

Zip Code(required)