Conscious Capitalism Senior Leader Network Self Nomination Form

Thank you for your interest in joining the Conscious Capitalism Senior Leader Network Please use this form to nominate yourself to join the Network. If you have questions prior to filling out this form, please reach out to Maria Gee at maria.gee@consciouscapitalism.org.

Once the form is submitted, our Business Development team will reach out to you with next steps.

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* 1. First Name

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* 2. Last Name

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* 3. Title

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* 4. Company Name

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* 5. Email address

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* 6. Phone Number

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* 7. Assistant Name

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* 8. Assistant Email Address

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* 9. Assistant Phone Number

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* 10. Name of the person who referred you, if any

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* 11. LinkedIn Page

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* 12. What was the 2019 revenue (or 2020 if revenue wasn't heavily impacted by COVID-19) for your business?

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* 13. Number of employees

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* 14. Are you involved with a Conscious Capitalism chapter?

Yes

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* 15. Which one? (Type N/A if not applicable)

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* 16. How actively engaged are you with this chapter? (Type N/A if not applicable)

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* 17. Have you attended a Conscious Capitalism, Inc. event (virtual or in person) in the past?

Yes

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* 18. What makes the Senior Leader Network so valuable is its members and their underlying commitment to elevating humanity through business. Why do you consider yourself a Conscious Capitalist?

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* 19. What initiative(s) are you leading in your business that are aligned with Conscious Capitalism principles that you would want to share with the Network, either because it was successful or because you ran into challenges? What is an example of you putting Conscious Capitalism into action?

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* 20. All engagement with the Network is voluntary. But the value of the Network comes from the contributions of its members learning from and supporting one another. Are you committed to being a contributing member of the Network with the understanding that it works as an interdependent ecosystem that requires ongoing engagement?

I am fully committed.

I am committed with the understanding that my time is limited in 2021.

I cannot commit at this time due to mitigating circumstances but would still like to be considered.

Please share more about your response above.

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* 21. Are there other senior leaders in your organization that may want to join the Network either now or in the future?

Yes, I know of at least one.

No, not at this time.

Maybe, I'd like to learn more and share with some colleagues.

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* 22. If you know the names of those senior leaders, please list below (add a comma between names).