STRATEGIO: Strategic Management Programme

For Biomedical Industry Executives

APPLICATION FORM

Selection procedure

The organizers will make a first judgement based on the application submitted by the candidate. Selection is made on the basis of the present application form.

Instructions

Your application should contain the following items:

1.  Completed application form

2.  Recent curriculum vitae

Applications should be sent to the attention of Rose-May DELRUE at .

Tel/ + 32 (0)71/251.027.

Deadline

The application deadline for the September 2013 intake is 2nd September.

1. Biographical data

¨ Mr. ¨ Mrs. ¨ Ms.

Family Name

Forename(s)

Date of Birth (Day/Month/Year) / /

Place and country of birth

Citizenship

Present address

Fax Tel E-mail

Company

Position

Business address

Fax Tel E-mail

Mother tongue

English: A (Fluent), B (Good working knowledge), C (Simply ability), D (Some understanding)

¨ Read ¨ Written ¨ Spoken

2. Educational Background

Please list your degrees, starting with most recent.

First Degree / Main Subject / Institution / Dates

3. Professional Experience

Please list your professional experience, starting with most recent.

Position or mission / Company / Dates

How many years (years + months) have you been working in total?

Current occupation, please give a brief description of your current mission in your company.

4. Motivation

Please state: Why you wish to participate in Strategio, and how would this programme benefit your career and personal development.

5. How did you first hear about the Strategio?

£ Friend £ Colleague

£ Professor £ Mailing (by post)

£ E-mailing

£ Google/ search engine

£ Web-site (please specify): …………………………………………………………………………………………

£ Press (please specify): …………………………………………………………………………………………

£ Event /Fair/ Forum (please specify): ………………………………………………………………………………………….

£ Newsletter (please specify):

………………………………………………………………………………………….

£ Other (Twitter, Facebook, …): …………………………………………………………………………………………


Billing Data

Accrodind to the programme Fee*: …………..€ including training manuals and other course materials, daily lunches, and morning and afternoon refreshments.

Upon approval of your application by the Admission Board, the tuition fees will be invoiced before the beginning of the programme.

If you intend to pay by private means, do you want the invoice to be sent:

¨ to your personal/home address

¨ to your attention, to your business address

If the invoice is to be addressed to your company, please fill in the blanks here below:

Name of the person to whom the invoice should be sent…………………………………

Organism:………………………………………………………………………………………

Position and department……………………………………………………………………...

VAT Number (if applicable)…………………………………………………………………..

Purchase order or any other identification number………………………………………..

Address (if different from your business address) ………………………………………...

Zip code City ………………………………………………

Tel E-mail …………………………………………...

Signature……………………… Date………………………………

*8.200€ HTVA BioWin non-members • 5.600€ HTVA Corporate participants • 3.000€ HTVA SME participants • 1.500€ HTVA Academic participants

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