Massachusetts Global EIR – Statement of Interest form

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Thank you for your interest in the Massachusetts Global Entrepreneur in Residence Program.
Please note: This document is a Statement of Interest in the Global EIR program and is not an official application for the program. Candidates are not being assessed at this time. The total number of program participants will be based on potential funds appropriated by the Commonwealth of Massachusetts during the FY2016 budget process as well as any matching funds provided by the private sector or other interested organizations to support the program. Until those resources are identified, the program will only be accepting statements of interest from interested candidates.
To identify your interest, qualified entrepreneurs and those seeking an H-1B non-profit affiliation through their existing employer should fully complete and submit the following form, along with the documents requested.
As the program further develops, the Massachusetts Technology Collaborative will identify qualified candidates according to the program criteria listed on our website and will contact qualified candidates to request formal applications.

APPLICANT CONTACT Information

Full Name:
Telephone:
Email Address:
Current Street Address:
City: / State:
Country of Residence: / ZIP/Postal Code:

Visa Status

Citizenship/Passport Country:
Current or most recent visa:
Status:
Previous visas and dates:

Graduate-level Education

College or University:
Dept., Program, or Affiliation:
Primary area of study:
Degree:
Graduation date:
FOR STARTUPS: COMPANY INFORMATION
Company Overview: / Please provide a complete description of your company including mission statement, brief history, and any relevant background.
Year Founded
Target Customers and Market / Please briefly describe your target customers and corresponding market segments
Applicant’s Title/Role
Management Team / Please list all members of the management team, including Board of Directors.
Current employee headcount
Funding, Committed/Requests / Please describe your current status on seed funding; investment commitments, etc.
FOR H-1B Candidates Through Established Firms
Note: The following section is for those H-1B candidates that already have employment offers from H-1B approved companies and are interested in the cap-exempt non-profit H-1B through an affiliation with a non-profit, with the approval and participation of their current employer.
Applicant Title, Current or Projected Position:
Company Name and Location:
Company Overview: / Please provide a complete description of your company including mission statement, brief history, and any relevant background.
Supervisor and/or HR Contact / Name
Phone & Email
ADDITIONAL INFORMATION
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SUBMISSION GUIDELINES
·  Along with a completed Statement of Interest, please attach a current resume or curriculum vitae (CV) in PDF format.
·  Optional: Please attach an executive summary of a current company/startup business plan.
·  For all questions or to submit a completed Statement of Interest and supporting documents, please email .