Please complete these pages and fax to Gil Herman – 708-386-1156

Name: ________________________________ Title: ________________________

Company/Organization Name: ___________________________________________

Address:________________________________________________________________

City: ___________________________________ State: ______ Zip: ______________

Phone: __________________________________ Fax: __________________________

Email:__________________________________________________________________

Website:________________________________________________________________

Business Description:______________________________________________________

_______________________________________________________________________

Sales: ___________ # of Employees: ____________

Nominated by: ________________________________________________________

Phone: ______________________ Email: _____________________________________

Has the candidate had some introduction to Vistage? _____Yes     ______No

Level of interest – check one

_____  Unknown –  just passing along a name (not a desirable way – but, hey – I’ll take it!)

_____  Curious – wants to discuss a little more before moving forward

_____  Interested – wants to meet for a Telling Session (45 minutes) to learn more about Vistage and benefits of membership, costs, logistics

_____  Knows fair amount about Vistage (source _______________________) and wants to schedule a Selection Interview (90 minutes). At the end of the Selection Interview, we should be positioned to make a mutual decision regarding membership.

_____  Very interested – wants to attend meeting as guest to meet other members and experience first hand.

_____ Other:_________________________________________________

Next Step  – check one

_____  Gil should contact candidate by _______________________ (date)

_____  Candidate will contact Gil by ______________________(date)

_____  I will set up a time with myself, candidate, and Gil to get together by

__________________ (date)Remarks:

 

 

Thank you for this referral.  I’ll keep you posted on progress.  Gil