Partnership Application

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Partner with Essentia

To request consideration as an Essentia partner, please fill out the partnership application below.


First Name
Last Name
Address
City
State/Province
Postal/Zip
Phone
Phone 2
Email
Date of Birth


Personal Fact Sheet

1) Educational Qualification (beginning with the most recent)
Qualification	Year of Passing	Name of Institution





2) Current Occupation
a) Service	b) Business	c) Both

To be filled by those in service
Name of current employer:
Designation:
Previous work experience:


Period	Organization Name	Designation	Responsibilities






3) Does your professional background involve any of the following? (please tick the appropriate box)
1) Marketing / Sales	2) Software / Hardware/IT
3) Education / Training	4) Profit Center Management
5) Small Business Mgmt.	6) Other


4) Are you currently associated with any professional group / association? Yes No
If yes, give details:


5) Your social status
a) Do you have a criminal record?	Yes No
b) Are any criminal proceedings pending against you in any courts?	Yes No
c) Have you ever been charged for any unlawful acts?	Yes No

If you have indicated YES for any ofthe above options, please state details of the same here below



The Proposed Centre

1) City / Town where you propose to setup the new venture.
located in the state / province of


2) When do you propose to setup the new venture?
Immediately	Within the next 3 months		Next 3 to 6 months



State the reasons why you'd like to partner with Essentia.