Name

Job Title

Company

Address

City

State

Zip Code

Phone

Fax (optional)

Email

1. Please indicate which one of the following best describes your function
   • Senior Management Chairperson of the Board, Chief Executive Officer, President, Owner, Vice President, Treasurer, Corporate Secretary, Partner, Director, CFO, General Manager
   • Operating Management Manager, Supervisor, Department Head, Consultant
   • Sales/Marketing/Communications
   • Professional Doctor, Attorney, CPA, Educator, Public Official
   • Technical Engineer, Developer, Designer
   • Business Student
2. Do you have an ownership or stock position in your company?
   • Yes No
3. Please indicate which of the following best describes your business/industry
   • Accounting and Consulting
   • Advertising/Public Relations/Media/Marketing
   • Banking/Finance
   • Computer/Technical/Internet Services
   • Construction/Engineering/Real Estate
   • Government
   • Health and Medical Services
   • Insurance
   • Legal
   • Manufacturing
   • Nonprofit and Institutions
   • Retail Trade
   • Service Industries
   • Telecommunications and Utilities
   • Transportation and Shipping/Delivery
   • Wholesale Trade
   • Education