Course Date & Location

* City:

Philadelphia

* Course Date:

BBE#37 Session 1: December 2-5, 2008 BBE#38 Session 1: March 3-6, 2009

Personal Information

* First Name:

* Last Name:

* Home Address:

* City/State/Province:

* Zip/Postal Code:

Home Phone:

Cellular Phone:

Spouse's Name:

Company Information

* Company Name:

* Street Address:

* City/State/Province:

* Zip/Postal Code:

* Country:

* Work Phone:

* Company Fax:

* Email:

Admin. Assistant's Name:

Assistant's Phone:

Assistant's Email Address:

Job Information

How long have you been with the company?

Current job title/position?

How long held?

Number of employees under your management?

What budget amount are you accountable for?

Your manager's name?

Manager's title/position?

Your primary responsibilities?

Job History

Please list your previous job titles (and company names, if other than this company) during the past 10 years. Include a brief description of responsibilities and the number of employees under your management.

Background

Please list any major responsibilities you have for community activities, volunteer organizations or other non-business related endeavors.

Education

Please list educational programs which have had a significant impact on your professional development. Include any college and university degrees earned, when awarded, and the institution from which received. Also any teaching positions you hold presently or held in the past.

Participation Objectives

Given what you know so far about Building a Breakthrough Executive, what can you commit to accomplishing in your career and your development as a leader through your participation in the program? (This will mark the beginning of the conversation which will support you in achieving your objectives throughout your participation in the program.)

What would you like to contribute to your organization as a result of your participation?

What aspects of your leadership would you want to strengthen as a result of your participation?