2015 Tuck-WBENC Executive Program

2015 Tuck-WBENC Executive Program

brought to you by IBM

October 4-9, 2015

Palisades, NY

Application Deadline: Tuesday, June30th, 2015

Candidate Eligibility:

-Currently certified and in good standing as a women business enterprise by WBENC

-Must be the owner of the company

-Have a minimum of three years’ experience running a business

-Maintain a minimum annual sales volume of $300,000

Instructions:

1. Save this form to your computer

1. Use your keyboard tab button to navigate between fields.

1. Email the completed form to g

Contact Information

Name (First, Last Name):

Participant Information

Company Name:
Job Title:
Business Mailing Address:
City, State, Zip Code:
Business Phone number:
Cell Phone number:
Physical Business Address (if different than mailing address):
Business Phone:
Fax:
Email:
Website:
Emergency Contact:
Emergency Contact Phone:
Facebook/ Twitter info:

Company Information

WBENC Certificate #: / Date Certified:
Brief Company Description:
Industry (as in WBENCLink):
Year Business Began:
No. of years as majority owner of the company:
Number of Employees: / Full-time: / Part-time:
Volume of Sales for Years: / 2012
2013
2014

What % of your business is:

Local: % / National: %
Regional: % / International: %

Who are your top three customers?

Please describe your current position/function and responsibilities.

If accepted to the Tuck-WBENC Executive Program, what do you hope to gain from your participation in the program? How do you think this program will advance your business and you as a leader?

Your Professional Experience (Rate as Fair, Moderate or Strong)

Fair Moderate Strong

Accounting:

Business Process:

Business Strategy:

Finance:

Human Resources:

Marketing:

Total Years of Management Experience:

Billing for the Full Program: $3,750.00

To whom should the invoice for the program be directed?

NOTE: To submit credit card information, check here to receive form upon your acceptance:

Name:
Company:
Address:
City, State, Zip Code:
Phone: / Fax:
Email:

The$3,750 program fee includes tuition and course materials. Most meals and accommodations for WBEs are provided by IBM or WBENC.

By checking this box, I confirm self-payment of $3,750.00 for the cost of the program to be paid prior to my attendance in October.

I am also applying for the Dorothy B. Brothers Scholarship. If I am not awarded the scholarship, I will pay individually for the Tuck-WBENC Executive Program.

I can only attend the Tuck-WBENC Executive Program if I am awarded the Dorothy B. Brothers Scholarship. (NOTE: Please be sure to complete the separate Dorothy B. Brothers Scholarship application and company overview for eligibility)

CANCELLATION POLICY

Applications are due no later than June 30, 2015. Qualified applications are awarded on a first-come, first-serve basis as this program is limited to 50 WBEs. Eligible applicants exceeding this capacity will be placed on a waitlist. Program awards are non-transferrable and may not be deferred.

It is a requirement for participantsto attend the course in its entirety due to the importance that each attendee plays in the success of group sessions in the overall program. As such, awardees who fail to meet the attendance requirements or cancel will be subject to the following fee schedule:

Action / Fee
Cancellation Before August 11, 2015 / $300.00
Cancellation After August 11, 2015 / $3,750.00
Tardiness or Early Departure / $700.00 per day
No Show / $3,750.00

All cancellations must be submitted in writing by the above deadlines to: Lindsay Burger at .

Yes, I understand and agree to the cancellation policy. By checking this box, I understand that I am responsible for these fees in the event of cancellation and authorize my credit card to be charged.

NOTE: All applicants must agree to this policy in order to secure a seat in the program.

WBENC, IBM and the Tuck School of Business at Dartmouth actively support the equality of opportunity for all persons regardless of race or ethnic background, and no candidate shall be denied admission or otherwise be discriminated against because of race, color, creed, religion, sex, age, sexual orientation, national origin, or disability.

Tuck-WBENC Executive Program Application - 1