Project ECHO Partnership Agreement Request Form

Project ECHO Partnership Agreement Request Form

ECHO is excited to help your organization to become an official ECHO partner. Part of this process involves signing an Intellectual Property Agreement with the ECHO Institute. To generate this agreement, we need to collect some information from you. Please complete and submit the following form, and and ECHO Institute representative will contact you within 2-5 business days. If you have any questions, please send us an email at EchoReplication@salud.unm.edu.

Organization/Entity Name*

Please provide the full, legal name of your organization.

DBA*

Does your organization do business under a different name?

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DBA Name

What is the name your organization is doing business as (DBA)?

Language

What language do you prefer to receive legal documents in?

Select

Other language

You requested a language not listed. Please tell us what language you prefer to receive legal documents in.

Website

Please provide your organization's website url (if applicable).

Organization Address*

What is your organization's legal address?

Organization City*

Organization State/Region*

Organization Country*

Organization Zip/Postal Code

Primary Contact Name*

Please provide the name of the individual who should receive the partnership agreement for your organization.

Primary Contact Email*

Please provide the email of the individual who should receive the partnership agreement for your organization.

Primary Contact Phone*

Please provide the phone number of the individual who should receive the partnership agreement for your organization. Please include the country code if outside of the U.S.

Secondary Contact Name

Please provide an alternate contact name for your organization.

Secondary Contact Email

Please provide the email address for your organization's secondary contact.

Secondary Contact Phone

Please provide the phone number for your organization's secondary contact. Please include country code, if applicable.

Superhub

If applicable, please tell us if a Superhub recruited you to become a partner with Project ECHO and has agreed to provide you with training and support by selecting them below.

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Referral

Please tell us how you learned about Project ECHO.

Does your ECHO Hub/Org currently run Education programs?

(Early Childhood, K-12, or higher Education)

Select

Comments/Questions/Concerns:

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