Application Form

International Action Learning MBA

1. Personal Details
surname □m □f title

first / given names

postal address

post code place

country native language

date of birth place of birth

telephone fax

mobile e-mail

nationality I.D./ passport no.

do you have access to a personal computer? □ yes □ no do you have access to the internet? □ yes □ no

2. Organisation Details
name of company / organisation

your position

telephone fax

mobile e-mail

postal address

post code place

country

physical address

post code place

country

please provide a short description of the most important products and / or services of your organisation

3. Education and Training

please provide a chronological overview of your educational experience, a copy of your BA degree and/or IELTS or TOEFL
language test results.

educational / professional institution course / training date qualified

4. Working Experience

please provide a chronological overview of your working experience

name of company position held period employed

IALMBA_Appl_2011_NFP
5. Application
to enrol on the
□ International Action Learning MBA® through Netherlands Fellowship Programme Scholarship

6. Invoice Address
□ personal □ business
for the attention of

address (if different from those in point 1 or 2)

7. Signature
The signatory hereby applies for registration on the programme ticked under point five of this application form and agrees that
upon acceptance of this application by BSN a legal binding agreement between him/herself and BSN is established. Should the
applicant/student have misrepresented the truth in this application form then this should be grounds for termination of this
agreement by BSN, termination of the agreement based on this misrepresentation is no cause for restitution of the programme
fees to applicant/student.
Upon signing of this application form, the applicant registers for the programme ticked under point 5 and acknowledges that
he/she has read the cancellation conditions as stipulated in Article 4 of the General Terms of Agreement of Business School
Netherlands, which have been lodged with the Chamber of Commerce in Tiel, the Netherlands under number 11026614.

□ I have read and understand the General Terms of Agreement

this application form is signed by

company name

applicant's signature

place and date

IALMBA applications should be scanned and emailed to: registrar@bsn.eu along with the following supporting documentation
employer declaration
curriculum vitae / resume
copies of diplomas and/or certificates
copy of I.D. / passport
business card

Employer Declaration - Support by the Organisation

I / we hereby confirm that our organisation will support the studies of Mr./Ms. ________________________________________
who is applying to participate on the International Action Learning MBA programme with Business School Netherlands.
I / we acknowledge the Action Learning methodology and the structure of the programme and are aware that a vital element of
the programme focuses on key issues relevant to both applicant and his/her organisation. We commit our full support to the
applicants’ studies and the implementation of projects, which are focused on real managerial issues within this organisation.

Signature

this declaration is signed by

on behalf of (organisation) position

signature place and date

IALMBA_Appl_2011_NFP