C12 Key Player Application

Agreement of Terms

Yes, I am in agreement to these terms and conditions and desire to formally submit this application to C12 Greater Phoenix and C12, LLC for consideration. This must be checked before you can proceed with the questionnaire and application.

What is your starting month as a member?

What is your motivation for participating in the Key Player program? (Personal, professional, etc.)

What are your expectations and/or objectives for the next 12 months?

What C12 Greater Phoenix forum will you be attending?

Personal Information

Who will be your C12 Chair?

First and Last Name

Nick Name

Position Title (Example: VP of Operations, Director of Sales, other)

Company Name

Primary Market Area

Industry or Business Description

Years with Company

Years in Industry

Number of Employees

Contact Information

Business Phone Number

Cell Phone Number

Primary Email Address

Website Address

Company Address

City

State/Province

Zip/Postal

Home Address

City

State/Province

Zip/Postal

Date of Birth

Spouse's Name

Spouse's Phone Number

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C12 Key Players Questionnaire & Application

Personal Information

Contact Information