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MIT Sloan Executive Education - Step 1 - Registration

Program Application Enrollment Form

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Participants must complete the entire program in order to receive the program certificate of completion; there will be no partial credit granted for any program that is not fully completed. This program is not eligible for credit towards an MIT Sloan Executive Certificate or Advanced Certificate for Executives.

Platform Revolution: Making Networked Markets Work for You, May 1-22, 2017

Required fields in red.

Professional Information

Prefix
First (or Given) Name
Middle Name or Initial
Last (or Family) Name
Nickname/Familiar Name (for Name Tag) Preferred First Name for Name Tag (e.g. Joe vs. Joseph)
Name as it should appear on certificate (name only; no titles/prefixes, please)
Company/Organization
Job Title
Preferred Address Business  Home
Address Line 1
Address Line 2
Address Line 3
City
State/Province   Zip/Postal Code
State (International)
Country
Direct Work Telephone Country Code, Area or City Code, Telephone Number, Extension:
   
Mobile Phone (*Required by Faculty Director for the "Entrepreneurship Development Program") Country Code, Area or City Code, Telephone Number:
  
E-mail (The email address submitted should be the participant's own email address as it will become the participant's username in our system.)
Additional email - cc 1:
Additional email - cc 2:
* Please use the "additional email" fields if you would like to keep someone informed about your registration (e.g., administrative assistant, human resources manager, training and development manager, your home email address). Please note this contact will be cc'd on MIT Sloan Executive Education email correspondences only.
If you have a Referral Code, enter it here:
 
When you attend an MIT Sloan Executive Education program, you are joining a learning community. To foster learning and business networking, we share basic contact information with other participants during the program(s). Please select the level of information you wish to share:

  All logged-in users   Fellow program participants only   No one
Who can see my profile:    
Who can see my email address:    
  Show profile and bio   Show profile only   Exclude me from the Certificate Community
Certificate Community Visibility:    

Company/Organization Web site
Applying as a: Team
Individual

Education

Institution Location Degree Major Year of Graduation
MIT Alum If yes, School:

Additional Professional and Company-Related Information

Management Function/Area of Responsibility: Other:
Level of Responsibility Other:
Industry Other:

Summary of Work Experience
Please list your three most recent positions below.
Company Job Title Year(s)

Main/Current Responsibilities

Main Challenges/Current Issues
Please briefly indicate some of the main challenges you personally confront in your business.

Personal/Organizational Objectives
Please elaborate on what you specifically wish to gain by taking the program(s), and how this will help you achieve your business goals.

How did you hear about MIT Sloan Executive Education?
Please specify name of source or person who referred you

What factor had the most influence on your decision to attend the program?
Other
Dietary Restrictions
 




Please specify:

Emergency Contact Info
Name
Relationship
Primary Phone Country Code, Area or City Code, Telephone Number, Extension:
     
Secondary Phone Country Code, Area or City Code, Telephone Number, Extension:
     

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