Application

General Information
*Last Name	:
*First Name	:
Middle Initial	:
Name Suffix	:
*Badge Display Name	:	(Nickname/familiar name for name badge)
*Salutation	:	(Mr., Ms., Dr., etc.)
*Title or Position	:
*Company Name	:
Contact Information
*Company Address	:
Company Address 2	:
*City	:
*State	:
* Country	:
*Zip/Postal Code	:
*Office Telephone	:
Office Fax	:
*Email Address	:
*Assistant Name	:
*Assistant Email	:
*Assistant Telephone	:
*Emergency Contact	:
*Relationship to You	:
*Emergency Telephone	:
Company Information
*Company Website	:
*Ownership	:
*Revenue	:
*Number of Employees	:
*Reporting Levels	:	(Number of reporting levels above you, up to and including the Chief Legal Officer or General Counsel).
Work Experience
Please indicate your most recent two or three positions including your current role. (Most recent first)
*Company Name 1	:
*Title 1	:
*Start Date 1	:
*Company Name 2	:
*Title 2	:
*Start Date 2	:
*End Date 2	:
Company Name 3	:
Title 3	:
Start Date 3	:
End Date 3	:
*Years of experience	:	(Please estimate total number of years of professional experience.)
Education
*Undergraduate University	:
*Undergraduate Degree	:
*Undergraduate Graduation Year	:
*Law School/Graduate School	:
*Graduate Degree	:
*Graduate Graduation Year	:
Other Education	:
Other Harvard Executive Education Experience	:
*Company Description	:	Please describe your company briefly. (100 words or less)
*Challenges	:	What are the key opportunities and formidable challenges facing your company? (100 words or less)
*Responsibilities	:	Please describe your current responsibilities. (100 words or less)
*Goals	:	Please explain your goals and objectives briefly as they relate to attending this program. (100 words or less)
*Billing Payment Method	:
Sponsorship Information
Please fill out this section only if you are not currently a Chief Legal Officer or General Counsel. The Sponsor letter of recommendation should be sent to Shironda White by email to swhite@law.harvard.edu.
Name of Sponsor	:
Title of Sponsor	:
Email of Sponsor	:
Source Information
How did you hear about this program?
		HLS Executive Education Website Brochure Program Alumnus/a Faculty Information Session HR or Professional Development Director Other