Mentor Application | Chairmen’s RoundTable

All fields marked by an * are required.

Applicant Name*:

Address

City

State

Zip Code

Phone*

Email*

Are you currently serving or have served within the recent past two years as chief executive officer of a qualified corporation or privately owned business?*

Yes No

List company, business sector, title and length of service:

Have you served as the general manager or president, with full P&L responsibility, of a company, major division or subsidiary of a corporation?

Yes No

List companies, market sectors, title and length of service and annual revenue of each company at time of exit:

Have you served a cumulative total of five years on Boards of Directors? (These must meet the standards of a qualified corporation or a substantial not-for-profit corporation.)

Yes No

List company, business sector, title and length of service:

Describe your community service activities, listing names of any organizations and board service:

List and prioritize business sector experience:

List and prioritize areas of executive expertise:

List three career accomplishments:

Why are you interested in becoming a mentor at CRT?

How did you learn about Chairmen's RoundTable?*

Have you ever attended a Chairmen's RoundTable meeting?

Yes No

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“Thank you for your interest in becoming a mentor. We will get back to you shortly.”

We typically reply within 2-3 business days. If you have not heard from us in that timeframe, please contact us at 619.823.8658.