Mentor Application

Applicant Name: *

Street Address

Address Line 2

City

State

Zip Code

Phone Number *

Email Address *

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? *

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

0/500 characters

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

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

0/500 characters

Have you served a cumulative total of five (5) years on Boards of Directors? (These must meet the standards of a Qualified Corporation or a substantial not-for-profit corporation.)

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

0/500 characters

Describe your community service activities, list names of the organizations and board service:

List and prioritize business sector experience:

List and prioritize areas of executive expertise:

List three career accomplishments:

How did you learn about Chairmen's RoundTable? *

Have you ever attended a Chairmen's RoundTable meeting?

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The CRT Board of Directors will consider candidates who have unique and extensive operating experience in lieu of some Board experience as determined in the best interest of the CRT mission.

Our Vice Chair, Mentor Development will contact you to review your application.

Thank you for your interest in becoming a CRT Mentor.