APPLICATION FOR ADMISSION PLEASE SPECIFY SESSION DATE:

Please answer all questions. Application must be fully completed and signed before review by the Admissions Committee.
Please type or print legibly.

GENERAL INFORMATION
NAME:
Last (family) First Middle Initial Prefix (Mr., Ms.) Suffix (Jr., II)

NICKNAME/FAMILIAR NAME FOR NAME BADGE: □ MALE □ FEMALE

COUNTRY OF CITIZENSHIP: DATE OF BIRTH:

Month / Day / Year

TITLE OR POSITION: DIVISION (if applicable) :

COMPANY/ORGANIZATION NAME:

COMPANY/ORGANIZATION ADDRESS:
(P.O. boxes accepted outside U.S.) Street City State / Country Zip Code / Postal Code

COMPANY/ORGANIZATION TELEPHONE: FAX:

COMPANY/ORGANIZATION WEBSITE: EMAIL:

ULTIMATE PARENT COMPANY:

YOUR HOME ADDRESS:

Street City State / Country Zip Code / Postal Code

HOME TELEPHONE:

PREFERRED MAILING ADDRESS: □ HOME □ BUSINESS

LANGUAGE PROFICIENCY
Proficiency in spoken and written English is essential for participation in Harvard Business School Executive Education programs.
CONFIDENTIAL: For use by Admissions Committee only.

ORGANIZATION
If currently employed by an organization, please complete the following information.

YOUR ULTIMATE PARENT COMPANY YOUR COMPANY/DIVISION

Products / Services:

Annual Sales Volume $ □□□, □□□, □□□, □□□ $ □□□, □□□, □□□, □□□
(in U.S. dollars):

Number of Employees:

Number of reporting levels above you the applicant, up to and including the Chief Executive Officer of the parent company:

What is the title of the person to whom you report?

Please describe your organizational hierarchy or attach an organizational chart.

PLEASE CHECK YOUR CURRENT INDUSTRY (check one only):

Manufacturing Nonmanufacturing
□ Aerospace/Automotive/ □ Accounting (805) □ Investment Management (725)
Transportation Equipment (110)
□ Advertising (806) □ Military (906)
□ Agriculture, Food, and Beverage (210)
□ Advocacy/Legal Services (809) □ Printing/Publishing (605)
□ Biotechnology (165)
□ Broadcasting (606) □ Real Estate (415)
□ Chemicals (161)
□ Commercial Banking (705) □ Retailing/Wholesaling (505)
□ Consumer Products (205)
□ Computer-Related Services (855) □ Social Services (863)
□ Energy/Extractive Minerals (115)
□ Construction (420) □ Telecommunications (406)
□ Heavy Capital Intensive/
Raw Materials Suppliers (120) □ Consulting (807) □ Trading (506)

□ High Technology/Electronics (170) □ Education (910) □ Transportation (410)

□ Highly Diversified Manufacturing □ Engineering (808) □ Utilities (405)

and Nonmanufacturing (955) □ Entertainment/Leisure (856) □ Other Communications (610)
□ Machinery and Equipment Manufacturers (305) specify:
□ Food Service/Lodging (857)
□ Medical/Healthcare Devices (163) □ Foundation/Grantmaking (914)
□ Other Nonprofit (925)
□ Paper and Forest Products (121) □ General Government (905) specify:
□ Pharmaceuticals (162) □ Health Services (860)
□ Software (171) □ Other Services (865)
□ Insurance and Diversified Financials (710) specify:
□ Textiles (122) □ Investment Banking/Brokerage (715)
□ Other Manufacturing (310)
specify:

WHAT FUNCTION BEST DESCRIBES YOUR POSITION? (check one only):

□ Accounting/Control (AC) □ Logistics (LG) □ Purchasing (PC)
□ Engineering (EG) □ Manufacturing/Operations (MO) □ Religion (RG)
□ Finance (FN) □ Marketing (MK) □ Research & Development (RD)
□ Fundraising (DV) □ Medicine (MD) □ Sales (MS)
□ General Management (GM) □ Planning (PS) □ Teaching (TC)
□ Human Resources (HR) □ Product Development (PD) □ Other (OT)
specify:
□ Information Services (IS) □ Project Management (PM)
□ Law (LW) □ Public Relations (PR)
WORK EXPERIENCE
Please list your positions in reverse chronological order, starting with your current one. If all positions are in the same company, please give the major promotional
sequence.

NAME OF COMPANY TITLE OR POSITION FROM Month / Year TO Month / Year

PLEASE ESTIMATE TOTAL NUMBER OF YEARS OF PROFESSIONAL EXPERIENCE:

PLEASE EXPLAIN WHICH OF THE ABOVE POSITIONS, IF ANY, INVOLVED NEW VENTURES OR BUSINESS ACQUISITIONS.

ENTREPRENEURIAL HISTORY
I. HOW WOULD YOU DESCRIBE YOUR PAST EXPERIENCE WITH STARTING NEW VENTURES? (check one)
□ Very experienced □ Somewhat experienced □ Not experienced

ARE YOU CURRENTLY IN THE PROCESS OF STARTING A NEW VENTURE? □ YES □ NO

If yes, what stage are you in? (check one)
□ Identifying opportunities □ Developing product or service □ Growing the business
□ Looking for funding □ Ready to launch

HOW WOULD YOU DESCRIBE THE NEW VENTURE? (check one)

□ Part of an established firm □ Independent start-up

II. BRIEFLY DESCRIBE THE NEW VENTURE YOU PLAN TO START OR ARE STARTING.

III. WHAT SPECIFIC QUESTIONS DO YOU HAVE ABOUT YOUR NEW VENTURE THAT YOU WOULD LIKE TO SEE ADDRESSED IN THIS PROGRAM?

EDUCATION
UNIVERSITY YEAR

DEGREE (highest level attained) □ High-School only □ Two-Year College □ BS/BA □ MS/MA □ MBA □ Harvard MBA
□ JD/Law □ PhD □ M.D. □ Foreign Diploma □ Other

HAVE YOU ATTENDED OTHER HARVARD BUSINESS SCHOOL PROGRAMS?

PROGRAM DATE
WHAT FACTOR HAD THE MOST INFLUENCE ON YOUR DECISION TO APPLY TO THIS PROGRAM?
□ A previous participant of an HBS Executive Education program (4) □ Divisional VP or other manager or supervisor (335)
□ An MBA graduate of Harvard Business School (5) □ Harvard Business School faculty (6)
□ Human Resource Department (157) □ Local Brazilian Institution
□ Magazine advertisement (700) □ Direct mail package (720)
□ HBS email notification (6040) □ World Wide Web (600)
□ Electronic advertisement (6050) □ Other (specify):

CANCELLATION POLICY
Payment is due within 30 days of invoice date. Cancellations or deferrals must be submitted in writing up to 30 days prior to the start of the program to receive a
full refund. Due to program demand and the volume of preprogram preparation, cancellations or deferrals received within 30 days prior to the start of the program
are subject to a fee of one-third of the program fee; within seven days are subject to two-thirds of the program fee. Cancellations or deferrals after the start of the
program are subject to full payment. All subsequent cancellations or deferrals are subject to a cancellation fee.

Upon acceptance, payment is required prior to program start date.

SIGNATURE OF APPLICANT: DATE:

I certify that all the information and accompanying material provided in connection with this application are authentic and accurate.

SPONSORING ORGANIZATION
Participants may be company sponsored or may enroll independently.
Please indicate who will assume responsibility for payment of the program fee: □ participant □ sponsoring organization

If independent, please complete the following contact information for invoicing:

NAME:

MAILING ADDRESS:
Street City State / Country Zip Code / Postal Code

TELEPHONE: FAX: EMAIL:

If sponsored, please have a senior executive from your organization complete the following:
NAME OF ORGANIZATION:
nominates this senior manager for the Building Ventures in Latin America program. It is understood that this executive, if admitted, will be completely free of
official duties while participating in the program and that the sponsoring organization assumes responsibility for payment of the program fee. It is also understood
that this executive is proficient in fast-paced, conversational English.

SIGNATURE OF SPONSORING EXECUTIVE: DATE:

NAME:
Last (family) First Middle Initial Prefix (Mr., Ms.) Suffix (Jr., II)

TITLE OR POSITION:

ADDRESS:
(P.O. boxes accepted outside U.S.) Street City State / Country Zip Code / Postal Code

TELEPHONE: FAX: EMAIL:

In accordance with Harvard University policy, Harvard Business School does not discriminate against any person on the basis of race, color, sex, sexual orientation,
religion, age, national or ethnic origin, political beliefs, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities.

PLEASE RETURN THIS APPLICATION TO:

BY MAIL: ONLINE: BY FAX:

ADMISSIONS COMMITTEE Applications may be submitted ADMISSIONS COMMITTEE

Building Ventures in Latin America online at: www.exed.hbs.edu. Building Ventures in Latin America
Harvard Business School Click on “Apply.” Fax: +1-617-496-1731
Soldiers Field
Glass Hall, Third Floor
Boston, MA 02163-9986 U.S.
SCHOLARSHIP APPLICATION

Limited, need-based scholarship funding is available for the Building Ventures in Latin America program. To be considered for a scholarship, please provide the
following information.

PLEASE DESCRIBE THE FINANCIAL CIRCUMSTANCES THAT REQUIRE YOU TO REQUEST SCHOLARSHIP FUNDS.

HAVE FINANCIAL RESOURCES BEEN SECURED FOR YOUR NEW VENTURE AT THIS TIME? IF SO, PLEASE EXPLAIN THE FUNDING ARRANGEMENTS.

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