www.winwinkc.com 

Win-Win Self-Assessment for Board Readiness

 

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1. Are you currently or have you been an EXECUTIVE OFFICER/MEMBER of a SENIOR EXECUTIVE TEAM?

Are you currently or have you been an EXECUTIVE OFFICER/MEMBER of a SENIOR EXECUTIVE TEAM?   Yes No

2. EXECUTIVE POSITIONS you have held (Select all that apply):

EXECUTIVE POSITIONS you have held (Select all that apply):   CEO (Chief Executive Officer) President Managing Director/Managing Partner COO (Chief Operating Officer) CFO (Chief Financial Officer) CMO (Chief Marketing Officer) CSO (Chief Strategy Officer) CIO (Chief Information Officer)/CTO (Chief Technology Officer) Division/Subsidiary President/Head Executive Vice President/Senior Vice President Functional Unit Head General Counsel None

Other Executive Positions (please specify)

3. Names of the COMPANIES/ORGANIZATIONS where you have served in an EXECUTIVE POSITION:

Names of the COMPANIES/ORGANIZATIONS where you have served in an EXECUTIVE POSITION:   1
2
3
4
5

4. INDUSTRIES in which you have worked (Select all that apply):

INDUSTRIES in which you have worked (Select all that apply):   Academia Advertising Aerospace & Defense Agriculture/Farm Products Airlines/Aviation Alcoholic Beverages & Tobacco Apparel & Footwear Arts Automotive Banking/Credit Unions Biotechnology Broadcast & Cable Business Consulting Chemicals Communications/Public Relations Computers: Hardware Computers: Software Construction Distribution Education	Energy Entertainment/Media Engineering Environmental & Waste Management Financial Services Food & Nonalcoholic Beverages Government/Public Service Healthcare:Hospitals/Clinics Healthcare:Long-term Care Healthcare:Pharmaceuticals Healthcare:Products & Supplies Heavy Equipment & Trucks Homebuilding Hospitality/Restaurants/Hotels/Resorts Household (Major Appliances/Home Furnishings) Industrial Machinery Information Technology Insurance: Life & Health Insurance: Property Casualty Investment Services	Gaming Legal Licensing Marketing Manufacturing Medical Equipment & Devices Metals: Industrial Military Oil & Gas Paper & Forest Products Philanthropy Publishing Real Estate: Commercial Real Estate: Consumer Retailing Semiconductor Supermarket & Drugstores Telecommunications Transportation Utilities
Other (please specify)

5. Areas of FUNCTIONAL EXPERTISE and Years of Experience (Select all that apply):

	None	Less than 5 years	5-10 years	More than 10 years
Communications/Public Relations	*Areas of FUNCTIONAL EXPERTISE and Years of Experience (Select all that apply): Communications/Public Relations None	Communications/Public Relations Less than 5 years	Communications/Public Relations 5-10 years	Communications/Public Relations More than 10 years
Customer Service	Customer Service None	Customer Service Less than 5 years	Customer Service 5-10 years	Customer Service More than 10 years
Finance/Accounting	Finance/Accounting None	Finance/Accounting Less than 5 years	Finance/Accounting 5-10 years	Finance/Accounting More than 10 years
General Management	General Management None	General Management Less than 5 years	General Management 5-10 years	General Management More than 10 years
Human Resources	Human Resources None	Human Resources Less than 5 years	Human Resources 5-10 years	Human Resources More than 10 years
Information Systems/Technology	Information Systems/Technology None	Information Systems/Technology Less than 5 years	Information Systems/Technology 5-10 years	Information Systems/Technology More than 10 years
Legal	Legal None	Legal Less than 5 years	Legal 5-10 years	Legal More than 10 years
Marketing/Branding/Sales	Marketing/Branding/Sales None	Marketing/Branding/Sales Less than 5 years	Marketing/Branding/Sales 5-10 years	Marketing/Branding/Sales More than 10 years
Production/Operations	Production/Operations None	Production/Operations Less than 5 years	Production/Operations 5-10 years	Production/Operations More than 10 years
Public/Government Affairs	Public/Government Affairs None	Public/Government Affairs Less than 5 years	Public/Government Affairs 5-10 years	Public/Government Affairs More than 10 years
Research & Development	Research & Development None	Research & Development Less than 5 years	Research & Development 5-10 years	Research & Development More than 10 years
Strategy	Strategy None	Strategy Less than 5 years	Strategy 5-10 years	Strategy More than 10 years
Supply Chain/Logistics	Supply Chain/Logistics None	Supply Chain/Logistics Less than 5 years	Supply Chain/Logistics 5-10 years	Supply Chain/Logistics More than 10 years

6. LEVEL OF EXPERIENCE in the following areas (Select all that apply):

	Little to No Experience	Working Knowledge/Some Experience	Expertise/Significant Experience
Audit	*LEVEL OF EXPERIENCE in the following areas (Select all that apply): Audit Little to No Experience	Audit Working Knowledge/Some Experience	Audit Expertise/Significant Experience
Business start-ups	Business start-ups Little to No Experience	Business start-ups Working Knowledge/Some Experience	Business start-ups Expertise/Significant Experience
Cost reduction	Cost reduction Little to No Experience	Cost reduction Working Knowledge/Some Experience	Cost reduction Expertise/Significant Experience
Finance	Finance Little to No Experience	Finance Working Knowledge/Some Experience	Finance Expertise/Significant Experience
Foreign service (in-country)	Foreign service (in-country) Little to No Experience	Foreign service (in-country) Working Knowledge/Some Experience	Foreign service (in-country) Expertise/Significant Experience
Global operations	Global operations Little to No Experience	Global operations Working Knowledge/Some Experience	Global operations Expertise/Significant Experience
International Business	International Business Little to No Experience	International Business Working Knowledge/Some Experience	International Business Expertise/Significant Experience
Logistics	Logistics Little to No Experience	Logistics Working Knowledge/Some Experience	Logistics Expertise/Significant Experience
Mergers/acquisitions/joint ventures/divestitures	Mergers/acquisitions/joint ventures/divestitures Little to No Experience	Mergers/acquisitions/joint ventures/divestitures Working Knowledge/Some Experience	Mergers/acquisitions/joint ventures/divestitures Expertise/Significant Experience
Operational improvements	Operational improvements Little to No Experience	Operational improvements Working Knowledge/Some Experience	Operational improvements Expertise/Significant Experience
Product development	Product development Little to No Experience	Product development Working Knowledge/Some Experience	Product development Expertise/Significant Experience
Profit/loss	Profit/loss Little to No Experience	Profit/loss Working Knowledge/Some Experience	Profit/loss Expertise/Significant Experience
Regulatory/government affairs	Regulatory/government affairs Little to No Experience	Regulatory/government affairs Working Knowledge/Some Experience	Regulatory/government affairs Expertise/Significant Experience
Restructuring	Restructuring Little to No Experience	Restructuring Working Knowledge/Some Experience	Restructuring Expertise/Significant Experience
Risk management	Risk management Little to No Experience	Risk management Working Knowledge/Some Experience	Risk management Expertise/Significant Experience
Strategic planning	Strategic planning Little to No Experience	Strategic planning Working Knowledge/Some Experience	Strategic planning Expertise/Significant Experience
Succession planning	Succession planning Little to No Experience	Succession planning Working Knowledge/Some Experience	Succession planning Expertise/Significant Experience
Supply chain management	Supply chain management Little to No Experience	Supply chain management Working Knowledge/Some Experience	Supply chain management Expertise/Significant Experience
Technology	Technology Little to No Experience	Technology Working Knowledge/Some Experience	Technology Expertise/Significant Experience
Turnarounds	Turnarounds Little to No Experience	Turnarounds Working Knowledge/Some Experience	Turnarounds Expertise/Significant Experience

Other (please specify)

7. HIGHER EDUCATION qualifications (Select all that apply):

HIGHER EDUCATION qualifications (Select all that apply):   PhD (or equivalent) MBA MS/MA JD MD/DO/DC BA/BS None

Other (please specify)

8. TYPES OF COMPANIES that you currently serve or have served as a member of a board of directors (Select all that apply):

TYPES OF COMPANIES that you currently serve or have served as a member of a board of directors (Select all that apply):   Privately-held companies (<$50 million in revenue) Privately-held companies ($50-$500 million in revenue) Privately-held companies (>$500 million in revenue) Venture-backed companies Private equity portfolio companies Public companies (<$1 billion in revenue) Public companies ($1-10 billion in revenue) Public companies (>$10 billion in revenue) Large not-for-profit companies (>$10 million budget) (e.g., Hospitals, National/Global Research Institutions) Academic institutions

9. TYPES of COMPANIES that you are interested in serving as a member of the board of directors (Select all that apply):

TYPES of COMPANIES that you are interested in serving as a member of the board of directors (Select all that apply):   Privately-held companies (<$50 million in revenue) Privately-held companies ($50-$500 million in revenue) Privately-held companies (>$500 million in revenue) Venture-backed companies Private equity portfolio companies Public companies (<$1 billion in revenue) Public companies ($1-10 billion in revenue) Public companies (>$10 billion in revenue) Large not-for-profit companies (>$10 million budget) (e.g., Hospitals, National/Global Research Institutions) Academic institutions

10. Board of Directors COMMITTEE Experience (at company types listed in Question 9) (Select all that apply):

Board of Directors COMMITTEE Experience (at company types listed in Question 9) (Select all that apply):   Audit Compensation Executive Finance Investment Nominating/Governance None

Other (please specify)

11. Board of Directors LEADERSHIP Experience (at company types listed in Question 9) (Select all that apply):

Board of Directors LEADERSHIP Experience (at company types listed in Question 9) (Select all that apply):   Chairman (& CEO) Chairman (Independent) Lead/Presiding Director Vice Chair Treasurer Secretary Audit Committee Chair Compensation Committee Chair Finance Committee Chair Investment Committee Chair Nominating/Governance Committee Chair None

Other (please specify)

12. Please list the COMPANIES for which you have served as a member of the Board of Directors:

Please list the COMPANIES for which you have served as a member of the Board of Directors:   1
2
3
4
5

13. Please list the community-focused not-for-profit/civic/governmental/academic ORGANIZATIONS (e.g., KCPT, Arts Council, American Heart Association) for which you have served as a member of the Board of Directors:

Please list the community-focused not-for-profit/civic/governmental/academic ORGANIZATIONS (e.g., KCPT, Arts Council, American Heart Association) for which you have served as a member of the Board of Directors:   1
2
3
4
5
6
7
8
9
10

14. What makes you believe you can be successful in a corporate board role?

What makes you believe you can be successful in a corporate board role?

15. Why do you want to join a corporate board of directors?

Why do you want to join a corporate board of directors?

16. What unique contributions can you make to a corporate board of directors?

What unique contributions can you make to a corporate board of directors?

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17. Please provide your name and contact information:

Please provide your name and contact information:   Name:
Company:
Address:
Address 2:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP:
Email Address:
Phone Number: