Whetstone Application Form

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* 1. Please provide us with your contact Information.

Your name and title:

Company name:

Position:

Industry:

Email address:

Phone:

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* 2. Over the course of the next twelve months, my goals are:

1.

2.

3.

4.

5.

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* 3. Please list your top THREE challenges.

1.

2.

3.

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* 4. Most business are in the following stages. Please check the stage which represents where you are at the moment.

Growing

Stagnant

Declining in Growth

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* 5. Please give reason.

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* 6. Do you have written business and personal plans? Check if yes.

Business

Personal

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* 7. How would you rate yourself?

	Good	OK	Poor
Ability to plan	Ability to plan Good	Ability to plan OK	Ability to plan Poor
Ability to lead/manage	Ability to lead/manage Good	Ability to lead/manage OK	Ability to lead/manage Poor
Ability to communicate	Ability to communicate Good	Ability to communicate OK	Ability to communicate Poor
Ability to balance life/work activities	Ability to balance life/work activities Good	Ability to balance life/work activities OK	Ability to balance life/work activities Poor
Ability to control your own schedule	Ability to control your own schedule Good	Ability to control your own schedule OK	Ability to control your own schedule Poor

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* 8. Which of the following best describes you?

Outgoing

Reserved

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* 9. Which of the following best describes you?

People oriented

Task oriented

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* 10. My acceptance into a Whetstone Personal Board of Advisors is important to me because: (Your compelling "Why")