International Platform Association

Membership Qualification Questionnaire

Thank you for your interest in membership consideration for the International Platform Association (IPA), one of America's oldest organizations devoted to leadership, communication, public affairs, education, media, and the spoken word.

Please complete this questionnaire so the Membership Governors may better evaluate your qualifications and compatibility with the traditions and objectives of the IPA.

PERSONAL INFORMATION

Full Name: ________________________________________

Professional Title: __________________________________

Organization or Company: ___________________________

Business Address: __________________________________

City: __________________ State: ______ Zip: __________

Telephone: ________________________________________

Email: ____________________________________________

Website or Professional Profile: ______________________

PROFESSIONAL BACKGROUND

Primary Profession or Field:

Secondary Areas of Expertise:

Have you appeared before public audiences as a:

(Check all that apply)

[ ] Speaker

[ ] Lecturer

[ ] Broadcaster

[ ] Entertainer

[ ] Educator

[ ] Author

[ ] Journalist

[ ] Attorney

[ ] Political Leader

[ ] Business Executive

[ ] Clergy

[ ] Media Commentator

[ ] Master of Ceremonies

[ ] Trainer/Coach

[ ] Other: _______________________

PLATFORM & COMMUNICATION EXPERIENCE

Approximately how many public presentations, broadcasts, interviews, or speeches have you given in the past five years?

[ ] 1–10

[ ] 11–25

[ ] 26–100

[ ] 100+

Please describe your most notable speaking, broadcasting, leadership, or public communication experiences:

PUBLICATIONS & MEDIA

Have you:

Written books?

[ ] Yes [ ] No

Appeared on television or radio?

[ ] Yes [ ] No

Published articles or columns?

[ ] Yes [ ] No

Hosted podcasts, broadcasts, or public programs?

[ ] Yes [ ] No

If yes, please provide details or notable examples:

CIVIC & COMMUNITY LEADERSHIP

Please list organizations, boards, civic groups, educational institutions, charitable organizations, or professional associations with which you are or have been affiliated:

IPA COMPATIBILITY & INTERESTS

What interests you most about the IPA?

[ ] Public speaking and oratory

[ ] Media and broadcasting

[ ] Intellectual discussion

[ ] Networking with leaders

[ ] Entertainment and performance arts

[ ] Educational advancement

[ ] Civic engagement

[ ] Convention participation

[ ] Historical traditions of the IPA

[ ] Other: _______________________

PERSONAL STATEMENT

In a few sentences, please explain why you believe you would be a suitable member of the International Platform Association:

REFERENCES

Please provide the names of three individuals familiar with your professional reputation, public speaking ability, leadership, or civic involvement.

MEDIA & PRESS RELEASE DISTRIBUTION

If accepted, to which three newspapers, publications, or media outlets would you most likely send announcements or press releases?

OPTIONAL SUPPORTING MATERIALS

You may include:

[ ] Biography

[ ] Resume or CV

[ ] Speaker one-sheet

[ ] Media kit

[ ] Newspaper or magazine clippings

[ ] List of speeches or appearances

[ ] Book/publication list

[ ] Letters of recommendation

CERTIFICATION

I certify that the information provided is accurate and understand that submission of this questionnaire does not guarantee acceptance into membership.

Signature: ________________________________________

Date: ____________________________________________

"Talent, imagination, friendship, and the power of the spoken word."

Founded in the tradition of Daniel Webster and the American Lyceum movement.