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Membership Application
Name
First
Last
Title
Company
Phone
Email
Address
City
Province
AB – Alberta
BC – British Columbia
MB – Manitoba
NB – New Brunswick
NL – Newfoundland & Labrador
NS – Nova Scotia
NT – Northwest Territories
NU – Nunavut
ON – Ontario
PE – Prince Edward Island
QC – Quebec
SK – Saskatchewan
YT – Yukon
Current Industry
Consumer Product
Media/Entertainment
Technology
Financial Services
Natural Resources
Telecom
Government
Not For Profit
Transportation
Health & Life Science Professional/Business Services
Utilities
Hotel/Hospitality/Tourism
Retail
Manufacturing
Insurance
Other
Other (please specify:)
Current Functional Area of Expertise:
Operations
Sales
Customer Service
Technology
Marketing
Manufacturing
Finance
Legal
Public Relations
Administration
Other
Other (please specify:)
Age Level
Under 25
25-29
30-45
46-55
56+
Number of direct reports
Immediate Supervisor (title) and your reporting level from CEO/President
Number of years experience in management:
What are your primary interests in joining The Executive Roundtable? (Check all that apply)
networking with peers
developing my personal leadership skills/insights
meeting senior executives beyond my organization
would like to find a mentor
would like to become a mentor
would like to speak at executive roundtable events
interested in joining or starting a peer advisory forum
Other (please specify:)
Would you like to be contacted to learn more about any of The Executive Roundtable services at this time?
Yes
No
How did you hear about us?
Referral from other website
Referral from colleague
Roundtable Recap link
Search engine
Facebook
Linkedin
Event invitation
Other
If you selected other above please provide details