Page 1

Registration

Welcome to the 2024 Disability Equality Index! Here you can register for the United States version of the Disability Equality Index as well as any or all of the newly added international Disability Equality Index options of Brazil, Canada, Germany, India, Japan, the Philippines and the United Kingdom all from one convenient form. Registration for the 2024 Disability Equality Index is complimentary for current Disability:IN corporate partners. Please indicate your partnership status and company name below to get started.

Are you a Disability:IN Corporate Partner? (If unsure, please refer to this list of Disability:IN’s current Corporate Partners)

YesNo

Enter your Company name here

If your company name is not listed on the list above, please change your selection to “No” for Corporate Partner status or contact Disability:IN to inquire about your partnership status

Has your company previously completed the Disability Equality Index?

YesNo

Enter your Company Name

If your company name is not listed on the list above, please change your selection to “No” for Prior Disability Equality Index Participation or contact Disability:IN to inquire about your participation status.

Enter the name of your Company

No

Partner Id

Potential Partner Id

Page 4

Registration

Company Headquarters Information

Business Name (legal name including type of organization such as Corporation or LLP):

Country

Address Line 1:

Address Line 2 (Suite, Building, Floor, etc):

City/Town:

State/Province/Region:

Zip/Postal Code:

Company Website Address:

Main Phone Number (###-###-####):

Your company’s Primary Contact for the Disability Equality Index is the same as the person completing this form? (*NOTE: The Primary Contact is considered the individual primarily responsible for completing the Disability Equality Index submission and will be the main recipient for communications and updates related to the benchmark. The Primary Contact will possess log-in credentials and will be able to enter, review and submit information for the Disability Equality Index. The Primary Contact can also assign "Contributors" from their company who can also provide information. Contributors have limited access to view and input information, and Contributors are unable to submit final responses. Only the Primary Contact can submit the final benchmark response submission on behalf of their company.)

YesNo

Contact Information of Person Completing This Registration Form

First Name:

Last Name:

Job Title:

Department:

Country

Address Line 1:

Address Line 2 (Suite, Building, Floor, etc):

City/Town:

State/Province/Region:

Zip/Postal Code:

Email Address:

Primary Contact

First Name:

Last Name:

Job Title:

Department:

Country

Address Line 1:

Address Line 2 (Suite, Building, Floor, etc):

City/Town:

State/Province/Region:

Zip/Postal Code:

Email Address:

Secondary Contributor Contact

(Secondary Contributor Contact will be copied on Disability Equality Index reminders and results, and will be contacted if the Primary Contact is not available.)

First Name:

Last Name:

Job Title:

Department:

Country

Address Line 1:

Address Line 2 (Suite, Building, Floor, etc):

City/Town:

State/Province/Region:

Zip/Postal Code:

Email Address:

Tertiary Contributor Contact (Optional, but recommended)

(Tertiary Contributor Contact will be copied on Disability Equality Index reminders and results, and will be contacted if the Primary and Secondary Contacts are not available.)

First Name:

Last Name:

Job Title:

Department:

Country

Address Line 1:

Address Line 2 (Suite, Building, Floor, etc):

City/Town:

State/Province/Region:

Zip/Postal Code:

Email Address:

Additional Information

How did you learn about the Disability Equality Index? (Check all that apply)

Please specify:

Why are you taking the Disability Equality Index?

Page 5

Billing Information

Payment: Registration for the 2024 Disability Equality Index is USD $900 for non-partners of Disability:IN. This initial registration fee entitles your company to register for one country; each additional country registration is USD $200.

Payment Options: Visa, MasterCard, Discover, or American Express

Refund Policy: All registration transactions are final; no refunds will be permitted once a payment is submitted.

Total:

Billing Name

First Name:

Last Name:

Suffix:

Email Address:

Billing Address

Country

Address Line 1:

Address Line 2 (Suite, Building, Floor, etc):

City/Town:

State/Province/Region:

Zip/Postal Code:

Payment Information

Name on Card

Card Number

MM

YY

Code

Billing Email

Payment Code

This code is not required if paying by credit card

2024 Disability Equality Index Registration

Page 1

Registration

Page 2

Registration

Page 3

Registration

Page 4

Registration

Company Headquarters Information

Page 5