RUBY Award Questionnaire

Name

First Last

Date of Birth

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Title

Company Name

Hire Date

Please Answer Only One of the Following Two Questions

Option 1: What has been your work history with the current employer?

Option 2: As a business owner/ entrepreneur, detail the origins of your business. Describe your experience developing your business into its current form.

What is your educational background?

Are you a member of any trade organization in your industry? Do you hold (or have held) any position(s) with these organizations?

What do you consider to be your greatest professional accomplishment in your field? When was this achieved in relationship to when you began employment in your field?

Have you received recognition within your profession for your past accomplishments? If so, when, and how were you recognized?

What makes you stand out in your field?

What type of growth, achievements, recognition, change, or major company milestones has your company accomplished/received during your tenure? What has been your influence in those accomplishments or changes?

STATEMENT OF RELEASE

I GRANT 1ST STATE BANK, ITS REPRESENTATIVES AND EMPLOYEES THE RIGHT TO TAKE PHOTOGRAPHS OF ME IN CONNECTION WITH THE ABOVE IDENTIFIED SUBJECT. I AUTHORIZE ITS USE AND PUBLISH THE SAME IN PRINT AND/OR ELECTRONICALLY. I AGREE THAT 1ST STATE BANK MAY USE SUCH PHOTOGRAPHS OF ME WITH AND WITHOUT MY NAME AND FOR LAWFUL PURPOSE. INCLUDING FOR EXAMPLE SUCH PURPOSES AS PUBLICITY, ILLUSTRATION, ADVERTISING, AND WEB CONTENT.

Release Authorization*

I grant permission
I do not grant permission

Comments

This field is for validation purposes and should be left unchanged.

RUBY AWARD QUESTIONNAIRE

Please Answer Only One of the Following Two Questions

STATEMENT OF RELEASE