SE N IOR EXECU TI VE LEAD ER SHIP PR O G R AM — I NDI A AP PLICATI O N F O R A D M I S S ION

PLEASE SPECIFY SESSION DATE:

• Please answer all questions. This application must be fully completed and signed, and the Sponsoring Statement and organizational chart must be received, before review by the Admissions Committee. • Please have your sponsoring executive complete the enclosed Sponsoring Statement. This statement may be sent directly from the sponsoring official to the Admissions Committee or, if appropriate, may be sent together with the application. • Because of the need for some nationals other than US nationals to secure entry visas for the United States, applications are requested at least eight weeks before the start date of the first on-campus module. • This is a writeable PDF. You may type directly on this form, or print it and complete it by hand. Please type or print legibly. I certify that all the information and accompanying material provided in connection with this application are authentic and accurate. SIGNATURE OF APPLICANT:

DATE:

NOTE: You must use Acrobat Reader 9.0 or higher to complete, save, and send this form electronically.

GENER AL I N F O R M A T I O N NAME: Last (family)

First

Middle Initial

NICKNAME/FAMILIAR NAME FOR NAME BADGE: COUNTRY OF CITIZENSHIP:

Prefix (Mr., Ms.)

□ MALE

Suffix (Jr., II)

□ FEMALE

DATE OF BIRTH: Month/Day/Year

DIVISION (if applicable):

TITLE OR POSITION: COMPANY/ORGANIZATION NAME:

COMPANY/ORGANIZATION ADDRESS: (P.O. boxes accepted outside U.S.)

Street

City

COMPANY/ORGANIZATION TELEPHONE:

FAX:

COMPANY/ORGANIZATION WEBSITE:

EMAIL:

State/Country

Zip Code/Postal Code

State/Country

Zip Code/Postal Code

ULTIMATE PARENT COMPANY: YOUR HOME ADDRESS: Street

HOME TELEPHONE:

PREFERRED MAILING ADDRESS:

City

MOBILE TELEPHONE:

□ BUSINESS ADDRESS

□ HOME ADDRESS

LANG UAG E P R O F I C I E N C Y Proficiency in spoken and written English is essential for active participation in the fast-moving classes and small group discussions. If English is your second language, or if you have less than one year’s experience working in an English-speaking environment, please provide a brief statement documenting your proficiency. (The Admissions Committee also may require an interview.)

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CONFIDENTIAL: The information you provide below is for use by the Admissions Committee only.

OR G ANIZAT I O N

YOUR ULTIMATE PARENT COMPANY

YOUR COMPANY/DIVISION

Products/Services: Annual Sales Volume $ (in U.S. dollars):

□□□, □□□, □□□, □□□

$

□□□, □□□, □□□, □□□

Number of Employees: How many employees are under your direct supervision? How many reporting levels are above you, including the chief executive officer of the parent company? What is the title of the person to whom you report? Please describe your company’s organizational hierarchy. Also provide a copy of your company’s organizational chart. If submitting your application online or via fax, please email the organizational chart to [email protected] or fax it to +1-617-496-1731. (Organizational chart required.)

PLEASE CHECK YOUR CURRENT INDUSTRY (check one only): □ Agriculture

□ Entertainment

□ Professional Services

□ Apparel

□ Environmental

□ Raw Materials

□ Banking

□ Finance

□ Real Estate

□ Biotechnology

□ Food & Beverage

□ Recreation

□ Chemicals

□ Government

□ Retail

□ Communications

□ Health Care

□ Shipping

□ Construction

□ Hospitality

□ Technology

□ Consulting

□ Insurance

□ Telecommunications

□ Consumer Products

□ Machinery

□ Transportation

□ Education

□ Manufacturing

□ Utilities

□ Electronics

□ Media

□ Other

□ Energy

□ Not For Profit



□ Engineering

□ Pharmaceuticals

specify:

WHAT FUNCTION BEST DESCRIBES YOUR POSITION? (check one only): □ Accounting/Control

□ Logistics

□ Purchasing

□ Engineering

□ Manufacturing/Operations

□ Religion

□ Finance

□ Marketing

□ Research & Development

□ Fundraising

□ Medicine

□ Sales

□ General Management

□ Planning

□ Teaching

□ Human Resources

□ Product Development

□ Other

□ Information Services

□ Project Management



□ Law

□ Public Relations

specify:

ANNUAL COMPENSATION (INCLUDING BONUS) IN U.S. DOLLARS (check one only): □ $500,000

□ $101,000–$150,000

WO R K EXP E R I E N C E Please list your positions in reverse chronological order, starting with your current, or most recent one. If all positions are in the same company, please give the major promotional sequence. NAME OF COMPANY

TITLE OR POSITION

FROM (MM/YYYY)

TO (MM/YYYY or CURRENT if employed)

PLEASE ESTIMATE YOUR TOTAL YEARS OF PROFESSIONAL EXPERIENCE: PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR ORGANIZATION AND/OR BUSINESS UNIT.

PLEASE DESCRIBE YOUR CURRENT RESPONSIBILITIES, INCLUDING YOUR LEVEL IN THE ORGANIZATION. ALSO INDICATE WHETHER YOU HAVE PROFIT-AND-LOSS (P&L) RESPONSIBILITY IN YOUR CURRENT ROLE.

PLEASE EXPLAIN YOUR OBJECTIVES AND GOALS AS THEY RELATE TO ATTENDING THIS PROGRAM. ALSO DESCRIBE WHAT YOU THINK OTHER PROGRAM PARTICIPANTS MAY LEARN FROM YOU (I.E., PERSPECTIVES, SKILLS, EXPERTISE).

WHAT DO YOU ANTICIPATE YOUR CAREER PROGRESSION WILL BE OVER THE NEXT FIVE YEARS?

WHAT ARE THE MOST FORMIDABLE CHALLENGES FACING YOUR ORGANIZATION AND/OR BUSINESS UNIT?

ED UCATIO N DEGREE (check only highest level attained):

□ High School □ JD/Law

□ Two-Year College □ PhD

□ BS/BA □ MD

□ MS/MA □ Foreign Diploma

UNIVERSITY:

□ MBA □ Other

□ Harvard MBA

YEAR:

HAVE YOU ATTENDED OTHER HARVARD BUSINESS SCHOOL PROGRAMS? PROGRAM NAME

DATE

Please indicate, by putting an “X” in the appropriate box, the amount of prior experience and familiarity you have with each of the following areas or activities. STRONG Major job responsibility and/or formal academic training

MODERATE Working familiarity

LITTLE OR NONE Unfamiliar

General Management:

□

□

□

Accounting and Control:

□

□

□

Marketing:

□

□

□

Finance and Financial Analysis:

□

□

□

Human Resource Management:

□

□

□

Production or Operations:

□

□

□

Information Technology:

□

□

□

Other Expertise (please describe):

□

□

□

HOW DID YOU LEARN ABOUT THIS PROGRAM?

□ Direct mail package

□ HBS Executive Education website

□ Online advertisement

□ Social media

□ HBS email notification

□ Internet search

□ Print advertisement

□ Other (specify):

WHAT FACTOR HAD THE MOST INFLUENCE ON YOUR DECISION TO APPLY TO THIS PROGRAM?

□ A previous participant in an HBS Executive Education program Participant Name Program/Year

□ An MBA graduate of HBS

□ Human resource department

□ Division Head or Manager

□ Other (specify):

□ HBS­ faculty

□ HBS Executive Education Corporate Relations IF YOU SAW A PRINT ADVERTISEMENT, PLEASE SPECIFY WHERE:

□ The Economist

□ Fortune

□ The Economic Times

□ Harvard Business Review

□ Other (specify):

IF YOU SAW AN ONLINE ADVERTISEMENT, PLEASE SPECIFY WHERE:

□ BBC

□ Firstpost

□ LiveMint

□ Business Insider

□ Harvard Business Review

□ Other (specify):

□ Business Standard

□ The Hindu

□ Economic Times

□ LinkedIn

CA NCELLA T I O N P O L I C Y Payment is due within 30 days of the invoice date. Cancellations or deferrals must be submitted in writing more than 30 days before the program start date to receive a full refund. Due to program demand and the volume of preprogram preparation, cancellations or deferrals received 14 to 30 days before the program start date are subject to a fee of one-half of the program fee. Requests received within 14 days of the program start date are subject to full payment of the program fee. Upon acceptance, payment is required prior to the program start date. I have read the cancellation policy and agree to the terms stated. (please initial here)

SP O NSO R IN G I N F O R M A T I O N Harvard Business School Executive Education requires that a senior executive within the organization sponsor the applicant. (Please note that the sponsor must be someone other than the applicant.) Your application must be accompanied by a Sponsoring Statement. SPONSORING COMPANY/ORGANIZATION NAME: NAME: Last (family)

First

Middle Initial

Prefix (Mr., Ms.)

Suffix (Jr., II)

First

Middle Initial

Prefix (Mr., Ms.)

Suffix (Jr., II)

(P.O. boxes accepted outside U.S.)

Street

City

TELEPHONE:

FAX:

EMAIL:

TITLE OR POSITION: EMAIL:

BILLING IN F O R M A T I O N An invoice will be emailed to the individual indicated below. NAME: Last (family)

TITLE OR POSITION: COMPANY/ORGANIZATION NAME: COMPANY/ORGANIZATION ADDRESS: State/Country

Zip Code/Postal Code

Harvard Business School is governed by a set of community values that foster honesty, respect for others, and accountability for one’s actions. Harvard Business School considers these values essential for a safe and productive learning environment for all. In accordance with Harvard University policy, Harvard Business School does not discriminate against any person on the basis of race, color, sex or sexual orientation, gender identity, 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. Harvard Business School may disclose, without consent, “directory” information about students. However, under the Family Educational Rights and Privacy Act (FERPA), participants may request that the School not disclose directory information about them. Your FERPA rights are available at: http://www.exed.hbs.edu/Documents/ferpa.pdf. Please contact Enrollment and Admissions Services at [email protected], if you have concerns or wish to discuss your rights under FERPA.

P LEASE R E T U R N T H I S A P PL I C A T I ON: ONLINE: Applications may be submitted online at: www.exed.hbs.edu EMAIL: Applications may be submitted via email to: [email protected]

BY MAIL: ADMISSIONS COMMITTEE Senior Executive Leadership Program—India Harvard Business School Soldiers Field Boston, MA 02163-9986 U.S. or: Harvard Business School India Research Center Piramal Tower, 7th Floor, Peninsula Corporate Park, Ganpatrao Kadam Marg, Lower Parel, Mumbai-400013, India

BY FAX: ADMISSIONS COMMITTEE Senior Executive Leadership Program—India Fax: +1-617-496-1731 For questions on the status of your submitted application, please email [email protected] or call +1-617-495-6226.

January-17