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Member Application
Thank you for applying for membership to Executive Alliance! Your application will be reviewed by our Board of Directors at the next available opportunity.
20
Questions
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1
Contact Information
Name (Name will be used on name badge and in the directory)
Preferred Street Address, City, State, and ZIP code
Is this business or home?
Preferred email (for member communications)
Mobile Phone
LinkedIn profile URL
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2
Current Employer
Company/Organization Name
Title/Position
Business Street Address, City, State, and ZIP Code
Please Select
Sole proprietor
Small business
Middle market
Large corporation
Please Select
Please Select
Sole proprietor
Small business
Middle market
Large corporation
Company size
Business Phone
Length Of Time In Current Position
Please Select
C-Suite
Director
Manager
Please Select
Please Select
C-Suite
Director
Manager
Role level
Please Select
Communication Services
Construction/Development
Consulting
Consumer Discretionary
Consumer Staples
Energy
Financials
Healthcare
Industrials
Information Technology
Law
Media/Entertainment
Non-Profit
Real Estate
Utilities
Other
Please Select
Please Select
Communication Services
Construction/Development
Consulting
Consumer Discretionary
Consumer Staples
Energy
Financials
Healthcare
Industrials
Information Technology
Law
Media/Entertainment
Non-Profit
Real Estate
Utilities
Other
Company Sector
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3
Profile - Your "elevator pitch" about you (limit is 400 characters, will be used in member directory)
0/400
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4
Areas of expertise for board service (up to five - will be listed in directory)
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5
Key Prior Executive/Professional Roles
Upload your resume on the next page if you prefer
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6
Resume
Upload your resume (optional)
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: 10.6MB
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7
Education / Degrees Granted
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8
Personal Leadership
Provide specific examples of how you have assisted women in reaching their full leadership potential, and/or demonstrated support for their professional advancement.
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9
What public boards have you served on? Did you hold any leadership positions?
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10
What private boards have you served on? Did you hold any leadership positions?
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11
What government appointments have you fulfilled?
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12
What non-profit boards have you served on? Did you hold any leadership positions?
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13
What awards have you received recognizing your achievements?
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14
Which of your professional certifications or expertise would you like Executive Alliance members to know about?
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15
Please attach your headshot
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: 10.6MB
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16
What are you hoping to gain from membership in Executive Alliance?
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17
Which Executive Alliance Committees / Programs would you consider serving on? Click all of your interests and we will connect you with the chair of the committee to learn more.
Finance
Governance
Legislative Advocacy
Marketing & Communications
Membership
Mentoring
Partnerships
Programming / Events
Women on Boards
Mentor for the Effective Impact Mentoring Program
Annual Census Report Analysis
Women of Excellence Planning
Finance
Governance
Legislative Advocacy
Marketing & Communications
Membership
Mentoring
Partnerships
Programming / Events
Women on Boards
Mentor for the Effective Impact Mentoring Program
Annual Census Report Analysis
Women of Excellence Planning
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18
Please identify any current Executive Alliance members whom you know personally or professionally.
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19
Additional information you would like to provide to address EA Membership criteria
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20
Electronic Signature
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Executive Alliance Member Application
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