MODULAR EXECUTIVE MBA

L E A D E R S H I P,

E N T R E P R E N E U R S H I P,

S T E W A R D S H I P

MODUL AR

EXECUTIVE MBA

N Y E N R O D E . A R E W A R D F O R L I F E

APPLICATION FORM

IN BUSINESS & IT | IN FOOD & FINANCE | IN PUBLIC & PRIVATE

APPLICATION FORM MODULAR EXECUTIVE MBA

Business & IT Food & Finance Public & Private

Thank you for your ambition to take part in one of our Modular MBA programs. This application form can be used to apply for single modules or for a full program. Please fill out the form as detailed as possible.

I would like to start my custom-made program with the following module(s): Spring

Fall

For more information about our modules, please visit www.nyenrode.nl/modules

If my first choice is not possible, then the following module(s) also have my interest:

If the first choice is not available, we will contact you personally before we make your other choice final.

My intention is to follow my future module(s) within the following MBA track

Personal information

Family name M F

First name used Initials Date of Birth Place of Birth Title(s) before name name

Title(s) after your name Address

Postal Code City

Country Nationality Phone Private mobile E-mail

MBA in Business & IT MBA in Food & Finance MBA in Public & Private

Organization and Value of IT Strategie en Organisatie Public-Private Partnership Marketing and Technology Verandermanagement en Government en Corporate Organisatieontwikkeling Governance

Business and Cyber Resilience Ondernemerschap en Coöperatie Ondernemerschap en Coöperatie Strategy and Organization Risico en Financiering Bedrijfsprocessen en ICT Leadership and Cooperation Leiderschap en Samenwerken Markt, Recht en Ethiek Study trip Studiereis Studiereis

MBA in Business & IT MBA in Food & Finance MBA in Public & Private

Change Management and Mondiale Voedseleconomie Beleid, Strategie en Organisatie Organizational Development Duurzaamheid en Innovatie Verandermanagement en

Business Processes and Technology Bedrijfsprocessen en ICT Organisatieontwikkeling Risk and Finance Markt, Recht en Ethiek Risico en Financiering Market, Law and Ethics Leiderschap en Samenwerken

• Dates

• Degree attained: yes/no

Company name Current position Business mobile phone Business e-mail

Address

Postal code City

Country

The invoices may be send to:

My personal address My company address: Company name For the attention of With reference / PO number Digital invoice address (e-mail)

If the billing address is different from the above data: Address

Postal Code City

Please provide an overview of your professional experience and educational background in a separate document, using the guidelines below:

For your professional experience include:

• Company

• Title/position

• From – to

For education, management education and courses include:

• Name of Institution

• Name of major/course

Highest attained diploma (HBO/WO BA/ BSc MA/ MSc Other)

Dates (from – to) Name of institution Study major Degree attained Yes No Yes No Yes No Yes No

COMPANY

INFORMATION

BACKGROUND

• Description of the nature of your work, including main

responsibilities, number of employees under your supervision, budget involved et cetera.

NOTES AND

CONDITIONS

Cancellation policy

• In case of cancellation up to four weeks (20 business days) prior to the start of the module, no tuition fee or accommodation costs will be charged

• In case of cancellation within four weeks (20 business days) before the start of the module or in case of discontinuation during the course, 100% of all costs will be charged

Notification of cancellation must be made in writing only. The cancellation date is the date of e-mail or postmark.

Program costs

Participants will be charged a tuition fee per module. The module price includes all learning costs: a complete educational program, literature and other reading materials, access to all student facilities at the Nyenrode estate, digital study facilities and food and

Please describe your affinity with this track:

What is your ambition, and in what way do you expect the module(s) contribute to achieving this?

Would your intention be to complete the full MBA?

Yes No, I would like to follow one or more separate module(s) I don’t know yet

I would like to make use of the following Nyenrode facilities

No pre-arranged overnight stay Overnight stay during each block Overnight stay prior and during each block

For more information about the prices, please visit www.nyenrode.nl/investment

Do you have any dietary requirement?

No Yes, I would like:

How did you become acquainted with the Modular Executive MBA?

Via online advertisement Via social media Via mailing

Via offline advertisement (newspaper/magazine etc) Via employer, namely

Via a participant/alumnus, namely Other, namely

AMBITION &

INTENTION

OTHER

INFORMATION

SIGNATURE

beverages during classes. Overnight stays, travel expenses for the program on other locations (abroad) and personal costs such as telephone costs and bar are not included. The module price is VAT free.

Additionally it is possible to book overnight packages or overnight stays on last-minute basis (VAT charged).

Please visit www.nyenrode.nl/investment for the actual prices.

Admissions

Upon receipt of the application form and required documents, each application will be reviewed by the Admission Committee. This committee uses a rolling admission system and applications are therefore evaluated in order of receipt. Within two weeks you will receive a confirmation of acceptance or other notification about further procedures. Priority goes to current participants in enrollments for the next period. New participants may enroll for any remaining places in the modules at the latest six weeks prior to the start of a new module.

Please visit www.nyenrode.nl/requirements for a detailed description of the requirements for the program.

The undersigned hereby agrees to meet all financial obligations towards Nyenrode Business Universiteit in time. When financial obligations are not met, or when they are not met in time, any ensuing judicial or extra-judicial costs as well as the legal interest will be charged to the participant. All overdue claims are referred to a collection agency. Furthermore, participants who fail to meet their financial obligations during the program will be excluded from further participation in the program, and/or will not receive their certificates or diploma until full payment has been received. The undersigned agrees with the conditions as mentioned at

www.nyenrode.nl/mmbaterms and the general information provided with this application form.

Your registration information will be kept at Nyenrode and will not be given out to third parties. Nyenrode Business Universiteit will use your data for group formats, etc. Nyenrode will also use your data for transmitting information and / or special offers on our education. If you do not appreciate that please inform us and Nyenrode will deactivate your data.

All the information in this application package is true, accurate and complete to the best of my knowledge. I certify that I have formulated and written all narrative responses without assistance of any kind. I understand that withholding or giving false information will invalidate my application and make me ineligible for admission to Nyenrode Business Universiteit.

Please send the application form, including:

A copy of your highest attained diploma

A copy of your passport or ID card (no driver’s license) Detailed curriculum vitae

Place / date Signature

The total application package can be send to:

Nyenrode Business Universiteit, Admissions Modular MBA P.O. Box 130, 3620 AC Breukelen

The Netherlands

+31 346 291 010 [email protected]