PMI Champion Program Application Form - Pilot

Contact Information

PMI Membership ID Title Last Name First Name Middle Name Company Name Description of Organization Business Designation Address Line 1 Address Line 2 City State Zip Work Phone Number Cell Phone Number Preferred E-mail ID Alternate E-mail ID
Demographic Information

Mr / Ms / Dr/

Industry PM Expertise Global Experience Project Involvement
PMI Confidential Page | 1

How often do you travel for work purposes Are you open to travel on need basis occasionally outside organization What is your role within the organization PMI Confidential Page | 2 .Highest degree achieved Hours Available per month (in hrs) Volunteer Experience (in years and months) Name the Volunteer organizations involved with PMI Specific Information Are you familiar with the recent edition of PMBOK Guide and other PMI Standards Do you hold position in other PMI Components (REP. conferences. etc.) Are you familiar with the benefits of PMI Membership Emergency Contact Details Yes / No Emergency Contact Phone number Last Name First Name Phone Number About You Have you been a speaker/ presenter at seminars. etc. Chapters.

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