Executive Roundtable Application

Please answer the following questions to your best ability.

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* 1. Please provide your contact information

Name *

Organization *

Position Title *

Address

City/Town *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Which of the following best describes your organization?

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* 3. Which of the following categories apply to you?

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* 4. If your organization is an Association, how many member organizations do you have?

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* 5. If you are an Association, what is your geographical reach?

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* 6. In what range does your organizational budget fall?

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* 7. What is the mission of your organization?

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* 8. Do you report directly to a board of directors?

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* 9. If you don't report directly to a board, please describe your relationship to the board.

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* 10. About how many employees work at your organization?

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* 11. How many employees directly report to you?

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* 12. How do you self-identify?

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* 13. How many years have you been in your position?

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* 14. When you think of your current organizational context, what 3 things would you most like to get help with?

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* 15. What about your work most feeds your energy?

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* 16. On a scale of 1-10 (10 being the best), how would you rate your work/life balance?

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* 17. When you think of yourself as a whole organizational and community leader, what 3 areas would you most like to develop in yourself?

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* 18. If you were at the top of your game as a leader, what would that look and feel like?

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* 19. Why are you interested in participating in a Roundtable? What do you hope to get out of it?

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* 20. Roundtable meetings will rotate between member organizations. Are you willing to host, which means provide a location and some snacks/refreshments, at least once during the year?

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* 21. Are you willing to commit to participating in the Roundtable for a year (10 half-day meetings a year)?

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* 22. Would you be interested in finding out more about any of the following?

Executive Coaching (gives an opportunity to work deeper in a one-on-one relationship)

A half- or full-day strategizing session (an opportunity to delve quickly into an issue with a coach)

On-demand coaching (you get one-on-one coaching only when you need it)

Six-month leadership development group coaching program (build your leadership skills with the support of a facilitator/coach and a small group of other leaders)

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* 23. What else, if anything, would you like for me to take into consideration?