MEMBER PROFILE
Please fill this member profile out for your membership into the local CEO Chapter
CEO Member Name (as it should appear in print)
First Name
Last Name
CEO Member Preferred Email Address
example@example.com
CEO Member Company
CEO Member Title
Mailing Address (Preferred)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CEO Member Phone Number (Preferred)
Please enter a valid phone number.
Please upload a recent picture of the CEO Member
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Please upload a recent short bio of the CEO Member
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Upload your company logo
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CEO Member's Executive Assistant
Please fill this section out for your executive assistant's information
EA's Name
First Name
Last Name
EA's Email Address
example@example.com
EA's Phone Number
Please enter a valid phone number.
Executive Liaison
Please identify an internal associate as your executive liaison, who can serve as the primary contact on your behalf during your tenure as a member of CEOs Against Cancer. We kindly ask that the appointee has decision making abilities on behalf of the company.
Name
First Name
Last Name
Email
example@example.com
Liaison's Title
Liaison's Preferred Phone Number
Please enter a valid phone number.
Health & Wellness Contact
Please identify an internal associate on your health & wellness/HR team, who can serve as the primary contact for the company around anything related to employee wellness or benefits.
Health & Wellness Contact's Name
First Name
Last Name
Health & Wellness Contact's Email
example@example.com
Date of Submission
-
Month
-
Day
Year
Date
Please type any social media handles of the CEO Member and/or Company (Twitter, LinkedIn, and/or Instagram)
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