Please provide the following contact and project information:

Consultant Name
Project Title

Ship to Arrive Date (or Pick-Up Date)

Choose one of the following options for type of project:

Career Development Coaching Corporate Employee Development Job Profiling/Selection Leadership Development Research Sales Development Succession Planning Team Building Training Needs Assessment Training Program Other

Choose the language for the Questionnaire (if not English):

US English German Latin American Spanish Portuguese

Chose the language for the Report (if not English):

US English German Latin American Spanish Portuguese

By what method would you like the questionnaires delivered?

E-mail to Participant Fax E-mail to Consultant Mail Pick Up

How would you like the reports to be delivered?

(Note: The CentACS policy is that reports are sent to the qualified or certified consultant and not sent directly from CentACS to the end user.)

E-mail ($45) Mail ($55 + S/H) Mail w/ e-Mail copy ($60 + S/H) Pick Up ($55) Pickup w/ e-Mail copy ($60)

What report(s) do you need?

Supertraits & Subtraits
Competency Analysis (C-CAPs)
Consultant's Report (Complementary introduction is over; the cost is now $5)

If you chose to receive the competency analysis above (C-CAPs), then choose from ONE of the 3 options below:

1. A Standard Profile: For the WorkPlace C-CAP report, we provide infrastructure analyses for specific work competencies. You may select a standard set of competencies, or you may specify your own set. If you wish to use one of our standard sets, select your choice here from the drop-down list:

[ ] No Competencies Required Typical Manager Typical Leader Typical Leader/Manager Typical Leader/Non-Manager Typical O.D. Consultant Typical Sales Person All 54 Competencies Small Business Owner Supervisor--First Level Office Manager Middle Management--Department Head Project Management Executive--Strategic Business Unit Vice President--Sales Director of Information Technology Trainer, In-House, Full Time

2. An Already Established Custom Profile: If you have already identified with us a specific set of competencies for use with your WorkPlace reports, then please enter the name of that set here (e.g., "NewCo Supervisors"):

3. Select Competencies for This New Project (and perhaps for future projects): Now, from the list of 54 competencies that follow, select the competencies that you want to use with this project profile. Try to limit your choices to around 15 competencies, as a specific job does not typically require more than that.

Action Orientation                     Adherence to Policy                    Ambiguity and Paradox, Comfort with    Ambition                             
Analytical Thinking                    Business Acumen                        Change, Comfort with                   Competitiveness                      
Computer and Keyboarding Skills        Creativity                             Decision-Making Skills                 Delegation                           
Development of Personnel               Diplomacy                              Diversity, Comfort with                Entrepreneurship                     
Facilitation                           Flexibility                            Follow Through                         Future Orientation/Visionary Ability         
Hiring and Staffing                    Humor                                  Independently, Comfort Working         Informing Others                
Integrity and Trust                    Leadership                             Listening                              Managing through Systems           
Meeting Management                     Motivation of Others                   Numerical Accuracy                     Objectivity                          
Optimism                               Organization                           Overseas Work Success, Likelihood of   Paperwork, Comfort with              
Performance Focus                      Planning                               Political Savvy                        Presentation Skills                  
Quality Orientation                    Range of Perspective and Interests     Responsibility Acceptance              Risk Taking                          
Safety Orientation                     Sales Orientation                      Self Confidence                        Self Control                         
Self Development                       Service Orientation                    Teamwork and Cooperation               Technical Learning                   
Work/Life Balance                      Written Communication                  

If you would like to save this profile for use with future projects, please enter here the name for that profile:

Here please enter the name and e-Mail (if appropriate) of each person who will be taking the questionnaire(s), as you would like the names to appear on the reports.

• If you want questionnaires emailed directly to the participants and checked that box earlier, then include name and e-Mail address; otherwise just list the names.

Additional Reports (extra charge--refer to price list or contact CentACS for details):
STANDARD TEAMER (includes all 18 segments)

CUSTOM TEAMER (to select what you want from among the 17 specific optional segments, see chart below)
PARTNER
LEADER

CAREER GUIDER

LEARNER

If you have chosen a "Teamer" report:

If you have chosen a "Teamer" report, please provide the name of the report ("Standard", or, if custom, your name for the report), the name of the team, and a list of all participants to be included on that team here (first two lines are examples):

Putting Together Your Custom Teamer Report:

Please select only the Segments you want included in your final report, and the position (or order) in which you want them, by placing a corresponding number (1, 2, 3, 4, …) in the “Position” column.  They will be placed in order according to your numbering. You may pick as few as one segment or as many as 17 segments under the custom option. If you would like more than one custom Teamer, please send a separate email directly to Laraine Gans at lbgans@centacs.com .

If you have chosen a "Leader" report:

If you have chosen a "Leader" report, please provide the name of the report ("Standard", or, if custom, your name for the report) and the name of the individual you are requesting The Leader for:

Putting Together Your Custom Leader Report:

Please select only the Segments you want included in your final report, and the position (or order) in which you want them, by placing a corresponding number (1, 2, 3, 4, …) in the “Order” column.  They will be placed in order according to your numbering. You may pick as few as one segment or as many as 13 segments under the custom option. If you would like more than one custom Leader, please send a separate email directly to Laraine Gans at lbgans@centacs.com .

If there are other reports that you would like along with this project order, please enter them here:

Input the "Subject" information for the E-mail that will be sent to the individual who will be receiving the questionnaire:

If you would like to specify the E-mail message sent with the questionnaire (instead of the standard CentACS E-mail), please input it here:

Use the shipping address that CentACS already has on file? Yes No

Use the billing information that CentACS already has on file? Yes No

If you answered "Yes" to both of the two preceding questions, then you may skip to the end and "Submit" your order. Thanks!

If you need to specify a shipping address that is different from the one that CentACS has on file, please do that here:

Ship to Address (if applicable)
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

If your "bill to" address is different from the "ship to" address, and we do not have it on file for you, please enter here:

Name
Bill to Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Finally, please enter in the following space any other products you need, along with quantity and any other pertinent information.

Specify  any other comments: