NEN FACULTY LEADER ENROLMENT FORM

Please provide the information below to sign in as NEN Faculty Leader. After submission of the signed form, you will
start receiving all updates from NEN, invites for NEN Faculty Development Courses and various Networking Events and
other relevant communications to keep you connected with your NEN Community.

Institute Information:

Name of the Dean, Principal or Director: ___________________________________________________________

E-mail Id: ___________________________________________________________________________________

Name of Institute: _____________________________________________________________________________

Institute mailing address: _______________________________________________________________________

___________________________________________________________________________________________

City: _______________________________________________________________________________________

Institute area of focus: _________________________________________________________________________

Does your institute have the following? Please tick as applicable:

Incubation Centre Course in entrepreneurship for students

Course/workshop for entrepreneurs Plans to offer a course in entrepreneurship in the

academic year 2010 - 2011

If none of the above, please specify your tentative plan _______________________________________________

___________________________________________________________________________________________

What percentage of the institute graduates become entrepreneurs after graduation? Do you/your institute keep track?

___________________________________________________________________________________________

Applicant Information:

Title: (Dr./Prof./Mr./Mrs.): ___________________ Designation: _____________________________________

Name of Faculty Applicant: ___________________________________________________________________

Tel. phone no.: ________________________________ Mobile no.: _______________________________

Email id: ___________________________________________________________________________________

Your area of specialization: ____________________________________________________________________

No. of years you have been teaching: ____________________________________________________________

Your other interest areas: _____________________________________________________________________

Please list any awards/scholarships/accolades you have received or your institute has received under your
leadership

___________________________________________________________________________________________

___________________________________________________________________________________________

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Have you ever taught entrepreneurship? Yes No

If yes, please mention the following:

How many months/years have you been teaching entrepreneurship? __________________________

Stream of your student whom you taught entrepreneurship:

Engineering Management Arts, Science & Commerce College Others _________________

Please mention the way of you have taught entrepreneurship. Please tick the box which is applicable to you

Single workshop Full course in entrepreneurship

Series of workshops Entrepreneurship exercises or games

Individual lecture Entrepreneurship Activities like Entrepreneur’s talk,

movie screening etc

Which teaching methods do you normally use to teach entrepreneurship? Please give a specific example from
your classes. (Case study, experiential learning, group discussions etc)

___________________________________________________________________________________________

___________________________________________________________________________________________

Have you created any teaching material on entrepreneurship like exercises, cases, articles, journals etc? If
YES, please mention in details.

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Have you attended any entrepreneurship related workshops or training programs? If yes, please mention

Name of the program Training Date (From To) Name of University/Institute.

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___________________________________________________________________________________________
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___________________________________________________________________________________________

Have you engaged in entrepreneurship in your own life? For example, started a company, invested funds in a
startup. If yes, please give details.

___________________________________________________________________________________________

___________________________________________________________________________________________

What kind of support?

Are you working with or supporting any of Please tick (Course, Mentor or
the following: if applicable How Many? Informal Guidance)
Students who want to become entrepreneur
Alumni who want to become entrepreneur
Entrepreneurs

If you are mentoring entrepreneurs, please tick which stage they are into:

Pre Venture Raw Early Growth

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Please tell us your reason for becoming NEN Faculty Leader:

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___________________________________________________________________________________________
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___________________________________________________________________________________________
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___________________________________________________________________________________________

After joining NEN Community, describe how you see contributing to your over all development, to your E-Cell
and to your institution

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

What are your key expectations from NEN Community?

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_________________________________________________________________________________________
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___________________________________________________________________________________________

I agree to become a NEN Faculty Leader and lead entrepreneurship activities on my campus and beyond. I
hereby declare that all the information provided above are true to my knowledge and there is no
misrepresentation of facts.

Signed:

____________________________________ ________________________________
Applicant Director or Principal (with institute seal)
Name: Name:
Date: Date:
(Please sign after you read the institute information)

Please submit the completed and signed application to your NEN Consultant on the day of the NEN Orientation
Program

OR

Please send the completed and signed application to Chippi Pillai, NEN Education in any one of the following
ways:

Fax to: 080 4168 9194/95

E-Mail to: chippi@nenglobal.org (Only scanned copies with signatures)
Courier to: Chippi Pillai,
National Entrepreneurship Network,
Villa #2, Regent Place, Thubarahalli,
Ramgundanahalli Post, Varthur Main Road,
Bangalore – 560066
Ph: 080 4168 9195

You will receive an acknowledgement mail from NEN Education as soon as we receive your Application Form.

PRIVACY STATEMENT: By submitting this enrollment form you consent to the processing of your personal information by NEN solely
as described in this statement. NEN will use personal information provided by you through this form to process your enrolment,
correspond with you, and obtain your feedback in connection with any scheduled event, and to update our contact lists. In doing so,
your information may be transferred throughout the NEN group worldwide and shared with third parties who will be providing other
services. NEN will not sell or disclose your registration information to other third parties without your consent.

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