Professional Profile  
Name
Address
City/State/Zip
Preferred Phone
Alternate Phone
Email Address
How did you learn about this questionnaire and our database of board candidates?
Your current employment information:
Employer
Title
Is the company public or private? Public         Private
Years with this company
Annual revenue of company
Number employed by company
Industry
Employment history that is relevant to future board service:
Employer 2
Title
Is the company public or private? Public         Private
Years with this company
Annual revenue of company
Number employed by company
Industry
   
Employer 3
Title
Is the company public or private? Public         Private

Years with this company
Annual revenue of company
Number employed by company
Industry
More information about you:
In which of the following discipline(s) do you have professional expertise?  Select all that apply.
In which of the following industries do you have professional experience?  Select all that apply.
Please list all NON-PROFIT boards (or board committees) on which you have served:
Please list all FOR PROFIT or CORPORATE boards (or board committees) on which you have served:
Please describe any other service (not noted above) to civic, charitable, trade, or similar organizations:
Please list any undergraduate and graduate degrees and any professional designations:
Have you received any awards, been published, earned any other certifications, etc.? If so, please provide details:
Please share any additional information that makes you an attractive candidate for board service:
If you are willing, please share with us your gender, birth year and ethnicity (OPTIONAL):
gender
year born
ethnicity

 

  
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