Salutation

-None- Ms. Mrs. Dr. Prof.

First Name *

Middle Name

Last Name *

Email Address*

Business Phone *

Mobile Phone *

Company Name *

Division/Department *

Title/Position *

Which of the following is your primary job function within your current position *

-None- Administrative Data Analysis Education Engineering IT/Technology Healthcare Human Resources Manufacturing/Production Operations Research Development Scientific Analysis

Identify the industry or STEM sector *

-None- IT/Data Science Biosciences/Natural Sciences Healthcare Engineering Pharmaceutical Research Laboratory Manufacturing

Number of years in this position *

-None- (<)1 1 - 3 4 - 5 6 - 10 11 - 15 10 - 20 20 +

Number of Years of Work Experience *

-None- (<)1 1 - 3 4 - 5 6 - 10 11 - 15 10 - 20 20 +

Number of Years of Management Experience (Managing people, leading teams, P L responsibility, project leader) *

-None- (<)1 1 - 3 4 - 5 6 - 10 11 - 15 10 - 20 20 +

Which of the following best describes your managerial responsibility in your current role?

-None- Expertise in business, technical, scientific areas with supervisory responsibility of administrative staff only Supervise multiple employees and manage the activities of one operating unit, projects or program or research area Manage a major office, facility, lab or national program. Oversee those operating several units. General management. Corporate Officers/C-level/top level of management within your organization None of these

Education - What is your highest level of education *

-None- High School Some College Bachelor’s Degree Master’s Degree PhD Medical Doctor

Graduate of Stony Brook University

-None- Yes No

Date of Birth

Business Street Address

City

State

Zip

Company's Website

Company Size

-None- 1 - 100 100 - 1,000 1,000 - 10,000 Over 10,000

Is your company providing financial support for this program?

-None- Yes No

Why do you feel you are a good fit for this program? *

What do you hope to get out of it? *

What specifically do you think you can contribute to other participants at the program? *

Please upload a copy of your resume or provide a link to your LinkedIn profile. *

LinkedIn Profile