HBS-ACCION PROGRAM ON STRATEGIC LEADERSHIP IN INCLUSIVE FINANCE March 25-30, 2018 APPLICATION FOR ADMISSION

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1 HBS-ACCION PROGRAM ON STRATEGIC LEADERSHIP IN INCLUSIVE FINANCE March 25-30, 2018 APPLICATION FOR ADMISSION Please answer all questions. Fields marked with an asterisk (*) are required. This application must be fully completed and signed before review by the Admissions Committee. It is the applicant s responsibility to procure a visa for travel to the United States. This process generally takes three months and it is encouraged that applicants start this process as soon as possible. If you are having trouble completing this form, please contact hbsaccion@accion.org Submission details can be found on the last page of this application. The application deadline is December 15, GENERAL INFORMATION NAME: Last (Family) * First * Middle Initial Prefix (Dr., Mr., Ms.,) Suffix (Jr., II) NICKNAME/FAMILIAR NAME: o MALE o FEMALE COUNTRY OF CITIZENSHIP*: DATE OF BIRTH: Month/Day/Year BUSINESS TITLE*: ORGANIZATION*: ORGANIZATION ADDRESS: Street City/State Country Zip Code/Postal Code ORGANIZATION TELEPHONE: ORGANIZATION WEBSITE: YOUR HOME ADDRESS: Street City/State Country Zip Code/Postal Code HOME TELEPHONE: MOBILE TELEPHONE: PREFERRED SECONDARY ASSISTANT S NAME: ASSISTANT S

2 CONFIDENTIAL: For use by Admissions Committee only. ORGANIZATION For Financial Service Providers ONLY: Organization Data: To be filled out only by financial services providers, such as MFIs and banks. Others, such as regulators, policymakers, and investors, can skip this section. Total Portfolio Amount: $ Total Assets: $ Number of Loan Clients: Number of Savings Clients: Total Number of Clients: Percent of Clients at Base of Pyramid: Year Started: Legal Form of Organization: o Commercial Bank o Finance Company o Public Sector Bank o Not-for-Profit o Cooperative o Other: If you are a microfinance organization, do you report to the MIX Market ( o Yes o No Is your organization a member of any international networks? Please list them here: For regulators and policymakers ONLY: Are you a member of AFI? o Yes o No Please summarize your regulatory/policymaking function and area(s) or responsibility. For investors ONLY: Please give a brief description of your organization s investment strategy. Please list your company s total assets under management?

3 CONFIDENTIAL: For use by Admissions Committee only. What countries do you primarily invest in? ALL applicants: Please answer all of the following questions. Please give a brief description of your organization. * What role does financial inclusion play in your organization? * APPLICANT EXPERIENCE Please describe in detail your job responsibilities, and put your role in context within the larger organization. * Please list your three most recent positions in reverse chronological order, starting with your current one. Name of Company* Title or Position* From (month/year)* To (month/year)* EDUCATION Please list your university degrees and the universities from which you received them. * LANGUAGE PROFICIENCY Proficiency in spoken and written English is essential for participation in the HBS-Accion Program on Strategic Leadership in Inclusive Finance. Please indicate your level of proficiency*: o I am a native English speaker. o English is my second language but I use it every day. o English is my second language but I use it infrequently. o Please check here if you can t positively answer in one of the above categories. Your level of English may not be high enough to benefit from this program. We may contact you to determine your language ability.

4 SHORT ANSWER QUESTIONS CONFIDENTIAL: For use by Admissions Committee only. Please answer the following questions (max. 250 words each). 1. What challenges to advancing financial inclusion do you face as a leader of your organization?* 2. Where would you like to take your organization in the next five years? * FINANCING YOUR PARTICIPATION Please indicate how you will be financing your participation in the HBS-Accion Program on Strategic Leadership in Inclusive Finance. If a third party is financing your participation, please include a statement of endorsement from this party with your application. * Do you wish to apply for a scholarship? * o Yes o No If yes, please provide a written statement of 500 words or less that explains why a scholarship would help you attend the program. * *Note: We will be unable to provide you with any information regarding scholarships until December and will be sure to contact you should this information become available sooner. Please also note that we are not able to offer full scholarships, and due to high demand, we are unable to offer scholarships to all applicants who apply. Scholarships fall between 25%-75% of the total tuition fee. We encourage all applicants to plan ahead for these expenses by considering personal financing, alternative scholarship opportunities, or employer sponsorship.

5 VISA FOR TRAVEL CONFIDENTIAL: For use by Admissions Committee only. Please indicate if you have a visa for travel. * o Yes o No We encourage all applicants from abroad to begin the visa process for traveling to the United States as soon as possible. Applicants do not have to wait for a decision from the admission committee in order to begin the visa application process. It generally takes three months to finalize visa arrangements for travel. Please note that U.S. embassies generally do not grant same day visas, so you should schedule your visa appointment at least 3 weeks prior to the start of the program. All admitted applicants should secure their visas at least 15 days before the start of the program. CANCELLATION POLICY Upon acceptance, a 10% deposit invoice of the total program fees will be sent to you. All deposits are due 15 calendar days after receipt of acceptance notification. Deposit must be received in order to secure your spot in the program. If a deposit is not received within 15 calendar days, your spot in the program will be given away. Full payments are due 30 calendar days after notification of acceptance. This is also the last day to cancel participation and refund your deposit. If cancellation takes place after this date, deposits are non-refundable. Final payments are fully refundable if the cancellation is received 10 business days in advance of the program start date. Cancellation received after this date is not eligible for a refund, regardless of the reason for cancellation. Note: These timelines are subject to change depending on the date of acceptance into the program. SIGNATURE OF APPLICANT: DATE: I certify that I have read and accept the cancellation policy and that all the information and accompanying material provided in connection with this application are authentic and accurate. In accordance with Harvard University policy, Harvard Business School does not discriminate against any person on the basis of race, color, sex, sexual orientation, religion, age, national or ethnic origin, political beliefs, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities. o Check here to accept the terms of this policy. * HOW DID YOU HEAR ABOUT US How did you learn about the HBS-Accion Program on Strategic Leadership in Inclusive Finance? o Your organization s Human Resources o Program Alumni o Accion Africa Board Fellowship o listserv: o Other: o Accion staff o Accion Website: PLEASE RETURN THIS APPLICATION BY DECEMBER 31, 2016 BY MAIL OR COURRIER: BY BY FAX: ADMISSIONS COMMITTEE Applications may be ed to: ADMISSIONS COMMITTEE HBS-ACCION PROGRAM hbsaccion@accion.org HBS-ACCION PROGRAM Accion Fax: th Street NW Suite 400 Washington, DC 20005