Nonprofit Executive Program Registration Form
All Information is kept confidential between the Registrant and the Jim Moran Institute.
General Information
Class *
Tallahassee NPEP Class VIII Fall 2023
First Name *
Middle Name
Last Name *
Title or Position *
Birth Date
Highest Education Level *
Some High School High School Diploma or Equivalent Some College Technical Degree AA or 2-year Degree BA or BS Masters Level Degree JD/MD Degree Doctorate/PhD
Race/Ethnicity
American Indian / Alaska Native Asian Black / African American Hispanic / Latino Native Hawaiian / Pacific Islander White / Caucasian
Gender
Female
Male
Personal Contact Information
Email Address *
Phone *
Phone Type *
Home
Mobile
Other
Work
Phone2
Phone Type 2
Home
Mobile
Other
Work
Home Address 1 *
Home Address 2
Home City *
Home State *
Home Zip Code *
Organization Information
Organization Name *
Address 1 *
Address 2
City *
State *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
U.S. Minor Outlying Islands
Virgin Islands
Armed Forces Americas
Armed Forces Europe, the Middle East, an
Armed Forces Pacific
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip Code *
Type of Organization *
Animal Services Arts & Culture Association Disability Services Educational Services Elderly Services Emergency Services Employment & Economic Self-Sufficiency Environmental Services Foundation Health Services Youth Services Other
Describe your Organization *
Year Organization was Founded (yyyy) *
Nonprofit Legal Entity *
501(c)(3) 501(c)(6) Other
If "Other", please specify
Are you the Founder? *
Yes No
Is this a Home-based Organization? *
Yes No
Please provide your best estimates if the information is not yet available.
Current Full-time Employees (#) *
Current Part-time Employees (#) *
Current Contract Employees (#) *
Current Volunteers (#) *
Prior Year Gross Revenue *
Prior Year Expenses *
Annual Personal Compensation *
<$50,000 $51,000-$100,000 $101,000-$150,000 $151,000-$200,000 $201,000-$250,000 >$250,000
Work Experience
Please list your positions in reverse chronological order, starting with your most recent positions.
Name of Company / Organization *
Title or Position *
From-to (Year) *
_
Name of Company / Organization
Title or Position
From-to (Year)
Social Media
Please provide links to your website and social media pages
Website
www.facebook.com/
www.instagram.com/
www.linkedin.com/company/
www.linkedin.com/in/
www.twitter.com/
Narrative
Please describe your role and the critical decisions in which you are involved.
Role and Decisions *
What are your organization's most important goals for the next five years?
Goals *
Please describe the personal objectives you hope to achieve through participation in the NPEP and how they relate to the needs of your organization.
Personal Objectives *
Do you have any concerns about participation in the Nonprofit Executive Program?
Concerns *
How did you hear about us? *
Email Event/Conference Facebook Instagram Print Ad/Magazine Radio Promotion Other LinkedIn Social Media TAL Magazine Referral
If Referral, who referred you?
To assist us in matching the program agenda with the objectives of the participants, please check the box that most closely describes the amount of prior experience and familiarity you have with each of the following areas:
Strategic Planning *
Extensive Moderate Little None
Lean Business Model *
Extensive Moderate Little None
Marketing *
Extensive Moderate Little None
Technology *
Extensive Moderate Little None
Accounting *
Extensive Moderate Little None
Finance/Financial Analysis *
Extensive Moderate Little None
Human Resources *
Extensive Moderate Little None
Separate from this program, the Jim Moran Institute offers exclusive programs for FSU alumni and military Veterans. For informational purposes only:
Have you attended Florida State University?
Yes
Are you a Veteran or military spouse?
Yes
By submitting this registration, I acknowledge that attendance and participation in all sessions is mandatory. In addition, I consent to allow the Jim Moran Institute to use all photographs and videos taken at this event in future marketing efforts.
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