First Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip:

Country:

Phone:

Email Address:

Do you currently teach at a university, college, or other institution?
Yes No

If yes, what institution:

Do you plan to be teaching at a university, college, or other institution in the future?
Yes No

If yes, what institution:

Have you previously taught a course in entrepreneurship?
Yes No

If yes, please indicate:
Name of course Number of times taught
Name of course Number of times taught
Name of course Number of times taught

Please briefly explain any professional background you have with starting, running, financing, or advising entrepreneurial ventures.

Please briefly describe your highest level of academic achievement, including the major or field you studied.

Why do you want to attend the Experiential Classroom?
Provide a brief explanation.

Tell us something unique about yourself.

Have you attended SEE or any of the other LLEEP clinics?
Yes No

If so, please indicate which program and what year.

Are you currently a member of the United States Association for Small Business and Entrepreneurship (USASBE) (please note that this is not a requirement for acceptance to the Experiential Classroom)?
Yes No

Are you applying for one of our Riata/USASBE Scholarships to cover part of the costs of enrollment?
Yes No

If yes, Please briefly indicate why you require this assistance.