The Executive Experience

Participant Enrollment Form - Please complete and contact us with any questions.

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IEEE Member #
Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
Date of Birth

Which session will you be attending?

The Executive Experience ... The Executive Experience August 23-27, 2010 (San Francisco) The Executive Experience September 20-24 2010 (Kansas City) The Executive Experience October 18-22 2010 (Kansas City)

Preferred name for badge:

In Case of Emergency Contact:

Do you have any special Dietary Restrictions?

Educational Background

Description of Current Position

Management Career Goals

In the past five years, what other management and leadership courses have you attended and who were they offered by?

What professional associations do you belong to (not necessarily active in)?

Complete the following statement: this would be a great executive development experience for me if.....

Please indicate how you wish to be billed for this course.  If you select credit card payment; you will be emailed an invoice which will contain a link for payment information.

.... Credit Card (MC, VISA, AMEX) Company has already made payment arrangements Send Invoice - I will process for payment through company