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VOLUNTEER ADVISOR SURVEY
*
Name
*
Current Employer
*
Title
Work Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Work Phone
(Include area code.)
Mobile Phone
(Include area code.)
Work Fax
(Include area code.)
*
E-mail
Website
Type of Industry
1. Business Size by Annual Revenue
Up to $500,000
$500,000 - $1 million
$1 million - $10 million
$10 million plus
2. Other industries that you have experience working in and years of experience
Experience 1
Experience 2
Industry
Company
Years of Experience
Position
3. Are you Self-Employed?
Yes
No
4. Areas of Expertise & Years of Experience
(i.e., Marketing, PR, HR, Accounting, Legal)
Area of Expertise
Years of Experience
Primary
Secondary
Tertiary
5. Current professional organizations that you are a member of
1.
2.
3.
6. Teaching, coaching or mentoring programs that you have been involved with in the past
1.
2.
3.
7. How did you hear about, or who referred you to ATHENA
PowerLink
® program?
*Denotes a required field.
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