Date:

Date of Birth:

Name:

Preferred Mailing Address:

City:

State:

Zip Code:

Telephone:

Fax:

Cell phone / beeper:

Email:

Employer:

Address:

City:

State:

Zip Code:

Work Telephone:

Extension

Fax:

Email:

Website:

Secretary or Assistant's Name:

His/Her Extension:

Present Employer:

Type and mission of organization:

Position/Title:

Length of time in that position:

Is this your first such position?

Yes

No

How many employees does your agency have and how many of those report to you?

What is the annual revenue of your agency or business, rounded in thousands or millions of dollars?

$

Who are your top five funders?

(private, government, or other)

What is your annual nonsecured fundraising goal for this year?

On which fundraising approaches do you focus? Please rank your emphasis, 1 being the highest.

  Corporate Grants

  Planned Giving

  Foundation Grants

  Corporate Matching Gifts

  Government Grants

  Products for Sale

  Special Events

  Pledge Programs

  Individual Donor Giving

  Direct Mail

 Other

What three management challenges do you face?

Summary of previous major employment positions (or attach your bio or resume):

If you have any thinkers or writers whose works you admire and draw upon, please list their names:

List a few places where you find support now for your business and professional life and say why they are supportive.

What are your top three support needs in terms of this group?

Assistance in practical task completion
Values clarification
Business and technical strategy assistance
Emotional nurturing
Peer feedback on your organizational plans
Spiritual awareness
Other

Have you participated in previous CEO training or support programs? If so, please list.

What were the limitations of previous training programs in which you've participated?

Do you exercise?

Yes

No

Do you feel that your job schedule affects your ability to exercise regularly?

Yes

No

Do you eat as nutritiously as you would like?

Yes

No

Do your work demands affect the nutritional quality of what you eat?

Yes

No