The Empire Mindset - Questionnaire

The Empire Mindset
Interview Series Questionnaire
& Media Release Form
Thank you for agreeing to participate in The Empire Mindset Interview Series! This series features interviews, photographs and videos of CEO executives and entrepreneurs I’ve been privileged to work with through my graphic design and brand development work. I’m so grateful you’ve agreed to participate.

As my passion, and series brand, is "An idea today can be an empire tomorrow.", I use this feature to capture a bit about who the leaders I'm privileged to work with are, instead of only the important and influential work they do. I want these narrative profiles to inspire executives and rising leaders alike to expand their definitions of success and dream big about what they can become and accomplish in their own lives.

Please find my interview questions on the following page. Responses can be as verbose or succinct as makes sense for you. Write as much as you’re comfortable with, though, because this is one time when “it really is all about you!” When we have our recorded call, I will pull a few of these questions to ask you “live”, and may have follow-up questions to craft social media clips. We may also host a Live video interview to discuss your responses.

Please reach out with any questions, by email at launchwithrenee@gmail.com, or phone at (202) 557-8030. Thank you again for agreeing to participate!

With gratitude,

Renée D. Holtz
Executive Producer, Launch with Renée
Creative Director, Refined Concepts
Your Full Name*

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Your Short Bio*
- 1. What is your "day job"?
- 2. Who were your heroes, or mentors?
- 3. What is your best childhood memory?
- 4. What traits did you possess as a child that resembled traits of a leader? Do you have a funny story?
- 5. When did you decide you would be a/n [insert career choice], that this would be your journey?
- 6. If you weren't doing this work, what would life look like?
- 7. If you had it all to do over again, would you do anything differently?
- 8. Something that has always stuck with me is, “You don’t have to make the mistake to learn from it.” What is the toughest lesson you’ve learned, that you hope another entrepreneur can learn from you?
- 9. Reflect on your first major challenge in a leadership role. What resources did you have, or need and not have, to overcome it?
- 10. There is a lot of research demonstrating the value of diversity in leadership. Tell me about your experience as a leader in your industry. What has diversity looked like in your work?
- 11. Top businesses have a board of directors to help govern the business effectively. Who is on your personal board of directors?
- 12. What keeps you up at night?
- 13. What do you do for you that brings you absolute joy or peace?
- 14. What is your favorite book (any genre)? What book are you reading right now?
- 15. What is a skill you want to learn? Why?
- 16. When do you feel the most confident? What have you accomplished that makes you proud?
- 17. If you had to describe yourself in five words, what would they be?
- 18. How would you want to be remembered?
- 19. If your life were a movie, what would be your theme song and who would play your role?
- 20. Is there anything else you wish I'd asked you?
- I acknowledge that I will voluntarily disclose to the Author personal and intimate information and opinions about myself an other individuals, and I hereby confirm that none of the information disclosed by me during these discussions, or in written interview responses, was acquired as a result of a confidential relationship, violates any restriction or covenant made by me, discloses any trade secrets, or is in any way contrary to law.*
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- I understand and agree that the Interview (including any audio or video recording, photography, transcription and other elements of the Interview/Performance), which will be held by held by the Author, may be made available for commercial or non-commercial purposes, including Internet, webcasts, podcasts, streaming video, art exhibition, publication or any media, as the Author may determine in its sole discretion. This may include quotation from, publication or broadcast of Interview material, in whole or in part, in live or recorded programs, on the Internet, on social media, on social media, on the radio or through other forms of electronic or print publishing or distribution.*
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- In order to enable the Author to develop the Work in any manner that the Author may deem best, I hereby release and discharge the Author and his/her licenses, successors, and assigns, from any and all claims, demands, or causes of action that I may have against them by reason of anything contained in the Work, or any of the above uses, including any claims based on the right of privacy, the right of publicity, copyright or trademark infringement, slander, libel, defamation, or misappropriation.*
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- I hereby grant, assign, and transfer to the Author a world-wide, perpetual, nonexclusive, royalty-free license to use, in whole or in part, all of the rights, including all literary, publicity and property rights, to publish in any media, language or technology now known or later developed, to duplicate, remix, edit or otherwise use and dispose of the photographs or the recorded and/or transcribed Interview (except illegal, defamatory or pornographic).*
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- I further agree that: The Author may edit, reproduce, adapt or otherwise use the Interview or any part thereof either alone or in combination with other material including text, images, animation, graphics and video; I shall have no copyright or other rights to the recorded Interview, photographs or any benefits derived therefrom. However, I retain the right to use Interview content in other venues independent of the Author; I waive any right to inspect, review or edit the Interview for use in the Work or otherwise; The Author shall have no obligation to use the Interview in the Work or otherwise; The Author may use my name, image, or likeness, biographic information, or voice in connection with the Work.*
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- In consideration of the foregoing, the Author has agreed to provide me with a print-quality digital PDF copy and one printed copy of any Author publication including all or part of my Interview Materials, as published in its first edition upon publication. Upon request, the Author will also provide me with a first edition high quality digital copy of any graphic or video that incorporates my Interview Materials. I acknowledge and agree that I am not entitled to receive any other form of payment from the Author and/or his/her licensees, successors, and assigns.
- By signing this contract, all parties agree to all terms and conditions set forth in this agreement, including the non-refundable nature of the reservation retainer and all other payments made. Both parties represent and warrant that they have the full legal capacity to execute this contract.
- Signature*
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