EmailMe Form - 2015 International Company Advisor Application

Information on our International Business Week Programs can be found at: http://www.wbw.org/reader.aspx?pg=Programs_GDYNIA.htm

Please Note: This form uses ReCaptcha (TM) technology to keep your information safe and strictly confidential.

VOLUNTEER GENERAL INFORMATION

Volunteer Name *

First Last

Home Phone *

### - ### - ####

Cell Phone *

### - ### - ####

Personal Email *

Home Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Employer *

Job Title *

Work Phone *

### - ### - ####

Work Email *

Work Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Gender *

Male

Female

Ethnicity
(for statistical purposes only) *

Polo Shirt Type *

Mens (run big)

Womens (run small)

Polo Shirt Size *

INTERNATIONAL PROGRAMS

City of Boleslawowo, Poland – July 5 - 10, 2015

City of Gdansk, Poland – July 19-24, 2015

City of Gdynia, Poland – August 16-21, 2015

Choose the program you want to attend (1 and 2) in order of preference.

1st Choice *

Boleslawowo

Gdansk

Gdynia

2nd Choice *

Boleslawowo

Gdansk

Gdynia

OTHER INFORMATION

As a CA I hope to accomplish *

Three words that describe me are:

One *

Two *

Three *

Is there anything else you want to tell us?

THANK YOU LETTERS

THANK YOU LETTERS *

A thank you letter to my employer for my participation is not required.

Please send my employer a thank you letter for allowing me to participate in this program.

Name of person receiving letter

Title of person receiving letter

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

ADVISOR FEE PAYMENT INFORMATION

You will not be charged or invoiced for the registration fee until your application has been accepted.

Payment *

Please send me an invoice for the $200 advisor fee.

Please charge my credit card for the $200 registration fee.

Other

Credit Card

Visa

Mastercard

American Express

Discover

Account Number

Expiration Date

Security Code

Name on Card

Billing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

CONSENT TO BACKGROUND CHECK

(REQUIRED)

I CONSENT TO A CRIMINAL BACKGROUND CHECK.
(Digital signature) *

(NAME - First, MI, Last)

Date of Birth *

MM / DD / YYYY

Today's Date *

MM / DD / YYYY

Date of Birth *

In order to process your travel plans, our travel agency requires your date of birth. Please list as dd/mo/yyyy. Thanks.

International Business Week, Washington Business Week and the Pathways are programs of The Foundation for Private Enterprise Education 501(c)(3). We provide equal opportunity to participate in all the rights, privileges, and activities sponsored by the organization regardless of the participant’s race, color, sex, national or ethnic origin, religion, or sexual orientation. The Foundation does not discriminate in the administration of its educational scholarship policies and strives to provide every participant full opportunity of participation in all scheduled activities.