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Candidate Profile Information
*
First
Middle
*
Last
*
Resume, Bio or CV
*
Photo / Headshot
*
Title
*
Organization
*
Occupational Area
Choose from the following industry / industry segment
--Please select--
Academic & Scholars
Arts & Entertainment:Art & Art Galleries
Arts & Entertainment:Broadcasting/News/Media
Arts & Entertainment:Performing Arts
Arts & Entertainment:Sports
Construction:Buildings, Infrastructure and Industrial
Financial Institutions & Alternative Investments:Banks
Financial Institutions & Alternative Investments:Family Office
Financial Institutions & Alternative Investments:Investment Banking
Financial Institutions & Alternative Investments:Private Equity
Financial Institutions & Alternative Investments:Venture Capital
Financial Institutions & Alternative Investments:Wealth/Asset Management
Government / Public Sector
Government/Public Sector:Ambassador, Diplomat or Governmental Representative
Government/Public Sector:Non-Governmental Organization
Health Care, Medicine, Health Sciences:Biotech or Medical Device
Health Care, Medicine, Health Sciences:Biotech or Medical Device
Health Care, Medicine, Health Sciences:Hospital
Health Care, Medicine, Health Sciences:Pharmaceutical/Research
Health Care, Medicine, Health Sciences:Technology
Hospitality & Retail:Amusement
Hospitality & Retail:Hotel
Hospitality & Retail:Merchandise Retail
Hospitality & Retail:Restaurant
Law
Manufacturing & Energy:Aerospace/Automative
Manufacturing & Energy:Chemicals
Manufacturing & Energy:Consumer Packaged Goods
Manufacturing & Energy:Food & Beverage
Manufacturing & Energy:Furniture & Textiles
Manufacturing & Energy:Oil & Gas
Manufacturing & Energy:Pharmaceutical
Manufacturing & Energy:Utilities
Manufacturing & Energy:Other
Non-profit:Foundations
Non-profit:Membership/Trade Organization
Non-profit:Other
Professional Services:Human Resources
Professional Services:Management Consulting
Professional Services:Marketing/Advertising
Professional Services:Public Relations
Professional Services:Sales
Professional Services:Staffing / Recruiting
Professional Services:Training
Public Accounting & Financial Consulting
Real Estate:Architecture, Engineering and Related Services
Real Estate:Brokerage, Consulting, Development, Property Management
Technology & E-commerce:Computer Services
Technology & E-commerce:Electronics
Technology & E-commerce:Hardware
Technology & E-commerce:Software Development
Transition / Retirement
Transportation, Distribution, Logistics
Other
*
Number of years at your current position or company?
*
Number of employees worldwide
--Please select--
Under 50
Under 100
Under 1,000
Greater than 1,000
*
Operations outside the U.S. or Global Footprint?
--Please select--
Yes
No
Annual Revenue
Business Website Address
*
Business Address
Business Address Line 2
*
City
*
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
*
Zip
Country
*
Business Phone
*
Email
Cell Phone
Admin Assistant
Admin Phone
Admin Email
*
Do you hold any current board positions?
--Please select--
No board positions currently held
NFP
Private
Public
NFP and Private
NFP and Public
Private and Public
Are you an Entrepreneur, Founder or Start Up?
--Please select--
Entrepreneur
Founder
Start Up
No - I am not
*
Are you a C200 Member?
--Please select--
Yes
No
*
Are you an Economic Club Member?
--Please select--
Yes
No
*
Are you an Executives' Club Member?
--Please select--
Yes
No
*
Are you a TCN Member?
--Please select--
Yes
No
*
Are you an Expatriate?
--Please select--
Yes
No
What is your Ethnicity?
--Please select--
White
Hispanic or Latino
African American
Native American or American Indian
Asian / Pacific Islander
Other
*
Country of Origin
Country (if other than US) where you've had long-term residency?
Birthday
*
Home Address
*
Home City
*
Home State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
*
Home Zip
Home Phone
