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					                                     AIBM

                                            Amsterdam Institute of Business Management

Application for Executive MBA Programme




PERSONAL DETAILS:

Family name: ________________________________________________Gender: M/F____________

First name(s):_______________________________________________________________________

Initials: ____________________________________________________________________________

Title: _____________________________________________________________________________

Date of Birth: _____ / _____ /__________ Place of birth: ___________________________________

Nationality: ________________________________________________________________________

Private address: ____________________________________________________________________

Postal code +City: ___________________________________________________________________

Country: __________________________________________________________________________

Home phone: _____________________Mobile:_____________________Fax:___________________

Private E-mail:______________________________________________________________________

Emergency Contact Person: __________________________Phone:___________________________



EMPLOYMENT INFORMATION:

Current Employer: __________________________________________________________________

Address: __________________________________________________________________________

Postal code+ City: ___________________________________________________________________

Work Phone: __________________Fax:___________________Email:_________________________

Current Title: ____________________________Type of Industry: ____________________________

Name & Title of the person whom you report: ____________________________________________
Previous Positions held:

Company                    Country          Position                Dates            Areas of Expertise

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________



EDUCATIONAL INFORMATION

In reverse chronological order, list all colleges, universities, and other educational institutions
attended since secondary school and degrees received or about to receive.

Institute & Location                 Dates Attended                 Majors                    Degree Title

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Languages:

Mother Tongue: ____________________________________________________________________

Proficiency in other languages                        Basic         Intermediate              Fluent

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________
Briefly state your career objectives

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

What is your expectation of this programme?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

List your extracurricular activities and Achievements

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Have you ever been on academic probation or been dismissed from any college or university?

  Yes     No

If yes, when and from which university? _________________________________________________

Do you feel that your grades accurately reflect your abilities?

  Yes     No

If no, please explain on a separate sheet of paper.
Have you ever applied for admission to Amsterdam Institute of Business Management?

  Yes     No

If yes, give the details ________________________________________________________________

Have English been your primary language and medium of study?

  Yes     No

If no, submit a copy of passing an English Language Examination.

Do you plan to finance your Executive MBA through educational loans?

  Yes     No

If no, specify the source _____________________________________________________________


Please list 3 references who will submit letters of recommendation in support of your application.

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Applicants Agreement:

I certify that all information and statements provided are, to the best of my knowledge, accurate and
complete. I understand that all information provided will be held in strict confidence by Amsterdam
Institute of Business Management. Any items submitted in conjunction with this application will not
be returned or transferred. This application is made with respect to the upcoming Education
Program indicated.

Signature: ________________________________ Date: ___________________________________

				
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posted:5/19/2011
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