The Round Table 12 Application Name* First Last Business Name*Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you the sole decision maker in the business?* Yes NoIf No, explain*QuestionsWhat are you going to do in the next year to make your business more profitable?*What are you passionate about?*What's the most difficult business obstacle you've faced and how did you overcome it?*What business issues do you currently have that would need the most attention?*What value will you bring to the group?*What else would you like for us to know that has not been asked in this application?Disclaimer and SignatureDisclaimer* I agree to these terms.I certify that my answers are true and complete to the best of my knowledge. If this application leads to acceptance of membership in Roundtable 12, I understand that false or misleading information in my application or interview may result in my release. If accepted, I understand that the current annual dues are $1800. Dues will be prorated based on the date of your acceptance.Signature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
