TELL US ABOUT COMPANY

Date:

Name:

Title:

Company:

Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Email:

Your email address must be included for the submission to be processed.

BOARD BACKGROUND AND EXPERTISE

This section allows you to specify your preferences as to background and areas of expertise you desire for a Board Member.

Company Size (by annual revenues):    Please choose one Any size Less than $1 million $2-10 million $10-25 million $25-50 million $50-100 million $100 million - $1 billion Over $1 billion

Committee Work Experience:    Please choose one Audit Compensation Conflicts Contributions Empl. Relations Energy Executive Finance Membership Nominations Oversight Pension Profit Sharing Public Policy R&D Social Issues Stock Options Technology

Geographic Location of Candidate (Mark location only if required):    Please choose one Northeast Mid-West Southeast Northwest Southwest Mid-Atlantic

Time (Approximate number of hours expected to commit to this board):    Please choose one Less than 120 hrs. 120-140 hrs. 240-360 hrs. 360-480 hrs. 140-240 hrs. Over 480 hrs.

Director Compensation:    $Annual Retainer  |   $ Per Meeting Fees

Number of Years as Director:    Please choose one none 1-5 yrs. 5-10 yrs. 10+ yrs.

Type of Board Experience Preferred:    For Profit   Non-Profit

CANDIDATE BACKGROUND DATA

Please indicate the board committee, business background, and education experience required by using the following codes:

Board Committee(s) Experience:

Business Background:

Education (Please indicate the degrees that are required):

EXPERIENCE AND CONTACTS BY LOCATION

Please indicate the amount of experience and contacts required by using the following codes:

SPECIALIZED DIRECTOR'S SKILLS

Please indicate specialized expertise required using the following codes:

EXPERIENCE WITH CORPORATE CONSTITUENTS AND GOVERNMENT

For both areas below, please the indicate amount of experience required using the following codes:

Corporate Constituents:

Government Relations Experience:

OTHER RELEVANT EXPERIENCE DESIRED