First Name: *
Last Name: *
Title: *
Company: *
Type of Organization (public/private, etc.): *
E-mail: *
Phone: *
Fax:
Address: *
City: *
State: *	AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip code: *
Website:
Business Description ( core products, services & primary market served ) : *
Year business founded:
Year you joined:
Why Did You Join/Start the Company:
Revenue for 2005:	$0-2M $3-5M $6-10M $11-25M $26-50M $51-75M $76-100M $101 M
Revenue for 2006:	$0-2M $3-5M $6-10M $11-25M $26-50M $51-75M $76-100M $101 M
Revenue for 2007	$0-2M $3-5M $6-10M $11-25M $26-50M $51-75M $76-100M $101 M
Projected growth (%):
2008
2009
2010
Current number of employees:
Projected Employee Growth:
2008
2009
Number of Senior Staff (VPs):
A Formal Business Plan:	Is in place Is not developed
Do you have a formal Board of Directors or Advisory Board?:	Yes No
Do you anticipate receiving equity funding to grow this business in the next 2 years?:	Yes No
If yes:	Public Private
Please list any national recognition/awards your company has received if applicable (i.e. named to the Inc. 500 list, etc.):
Membership in other CEO organizations? If so, which one/(s):
Are you able to make a commitment to participation in a Roundtable Group (requires approximately 4 hrs/month):	Yes No
If You Are Able to Make a Roundtable Commitment to Open Sharing of Pertinent Experience and Knowledge,<br>Please Let l Us Know: <br>
What is important to you about the Roundtable group you join;
What is the best thing you will add to a Roundtable group;
Your prior experience or background;
What is your vision for achieving high company and professional growth:
Describe your personality type /
Hobbies and Interests:
Current Boards you serve on:
What time of day do you most enjoy attending business events:	Mornings Afternoons Evenings
Other Comments You May Wish to Add: