MEMBER PROFILE

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 NameLast Name
CEO Member Preferred Email Address
example@example.com
CEO Member Company
CEO Member Title
Mailing Address (Preferred)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CEO Member Phone Number (Preferred)
Please enter a valid phone number.Format: (000) 000-0000.
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 NameLast Name
EA's Email Address
example@example.com
EA's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 NameLast Name
Email
example@example.com
Liaison's Title
Liaison's Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 NameLast Name
Health & Wellness Contact's Email
example@example.com
Date of Submission

MonthDayYear
Date
Please type any social media handles of the CEO Member and/or Company (Twitter, LinkedIn, and/or Instagram)
I agree that the American Cancer Society (ACS) and its affiliates may use my name, likeness and any quotes I provide, as well as my company's name and logo in connection with the promotion of ACS's mission subject to my or my designee's approval. I understand that my company may use the American Cancer Society name and logo, the CEOs Against Cancer program name and logo and copyrighted materials supplied by ACS in connection with the CEOs Against Cancer program subject to ACS's approval.
Should be Empty:

MEMBER PROFILE

CEO Member's Executive Assistant

Executive Liaison

Health & Wellness Contact