C12 CEO Member Application

Required fields marked with *.

Agreement

I desire to become a member of C12 Greater Phoenix.

About You

What are your primary reasons and desired outcomes for joining C12?

What is your starting month as a C12 member?

What is working well in your business/organization?

What is not working well in your business/organization?

What were the two biggest decisions you made in the last year?

What are the most important decisions you are facing today?

What experience, background, and skill sets will you bring to add to the C12 Advisory Board?

How did you discover C12?

Forum Selection

What C12 Greater Phoenix forum will you be attending?

Who will be your C12 Chair? Please select from the list of chairs (Kathie Julian / Mike Stanley / Tim Smith)

Personal & Company Information

First and Last Name

Nick Name

Position Title (e.g., Owner, CEO, President)

Company Name

Primary Market Area

Industry or Business Description

Years with Company

Years in Industry

Number of Employees

Estimated Current Annual Revenue

Contact & Billing Information

Business Phone Number

Cell Phone Number

Primary Email Address

Website Address

Company Address

City

State/Province

Zip/Postal

Billing Contact Name

Billing Contact Email

Home Address

City

State/Province

Zip/Postal

Date of Birth

Spouse's Name

Spouse's Phone Number

Primary Church Name and City