APPLICATION FORM A
2016 LBS INTERNATIONAL BUSINESS TOUR TO THE UNITED STATES
Theme: Entrepreneurship and Innovation in Emerging Markets: Strategic
Challenges and Opportunities
March 19-28, 2016
Each application must be accompanied with a recent passport photo of the main
applicant’s international passport data page and each person accompanying him/her
on this trip. The photo should be clipped (not stapled) to the upper left corner of this
application form. Kindly attach a copy of evidence of payment of the Commitment
Fee. Please note all information provided is used for the application will be treated with
the utmost confidentiality and will not be shared with any third party.
Name:……………………………………………………………………….,,
Surname
Other Names
Home Address:…………………………………………………………........................
………………………………………………………………………………………………
Home Tel:……………………………Cell:……………………………….....................
Email:………………………………………………………………………………………
Institution/Employer:……………………………………………………………………
Institution/Employer’s Address:……………………………………….......................
………………………………………………………………………………………………
Position/Level:………………………………….Office Tel:…………….....................
Office Email:……………………………………………………………………………...
Functional area of specialization
Mkt
Operations
Finance
Gen Mgt
Hum Resc
Others
Citizenship:…………………………….Passport No.:…………………………………
Country of Issue:…………………….. Place of Issue:……………………………….
Issue Date: _ _/_ _ _/_ _ _ _
Expiration Date: _ _/_ _ _/_ _ _ _
Date of Birth: _ _/_ _ _/_ _ _ _
Marital Status (tick): Single
Place of Birth: …………………………………..
Married
Divorced
Separated
If married, proceed to fill this section
Name of Spouse:………………………………………………………………………..
Surname
Other Names
Occupation:…………………………………………………………….......................
Institution:…………………………………………………………………………………
Institution’s Address:……………………………………………………......................
………………………………………………………………………………………………
Work Phone:……………………………Cell:………………………………................
Email:………………………………………………………………………………………
Position/Level:…………………………………………………………….....................
Citizenship:………………………….. Passport No.:…………………………………
Country of Issue:…………………… Place of Issue:………………………………..
Issue Date: _ _/_ _ _/_ _ _ _
Expiration Date: _ _/_ _ _/_ _ _ _
Date of Birth: _ _/_ _ _/_ _ _ _
Place of Birth: ………………………………
If you plan to participate in the program with your minor child/children,
proceed to fill this section
Minor Child 1
Name of Child:…………………………………………………………………………..
Surname
Other Names
Date of Birth: _ _/_ _ _/_ _ _ _(Age: _ ) Place of Birth: …………………………....
Citizenship:…………………………….Passport No.:…………………………………
Country of Issue:…………………….. Place of Issue:……………………………….
Issue Date: _ _/_ _ _/_ _ _ _
Expiration Date: _ _/_ _ _/_ _ _ _
Minor Child 2
Name of Child:…………………………………………………………………………..
Surname
Other Names
Date of Birth: _ _/_ _ _/_ _ _ _(Age: _ ) Place of Birth: …………………………....
Citizenship:…………………………….Passport No.:…………………………………
Country of Issue:…………………….. Place of Issue:……………………………….
Issue Date: _ _/_ _ _/_ _ _ _
Expiration Date: _ _/_ _ _/_ _ _ _
Child
Name of Child:…………………………………………………………………………..
Surname
Other Names
Date of Birth: _ _/_ _ _/_ _ _ _(Age: _ ) Place of Birth: …………………………....
Citizenship:…………………………….Passport No.:…………………………………
Country of Issue:…………………….. Place of Issue:……………………………….
Issue Date: _ _/_ _ _/_ _ _ _
Expiration Date: _ _/_ _ _/_ _ _ _
PERSON TO CONTACT IN CASE OF EMERGENCY:
Name:……………………………………………….Relationship:……………………
Address:…………………………………………………………………………………..
………………………………………………………………………………………………
Home Tel:……………………………….. Cell:…………………………………………
Day Tel:……………………….Email:……………………………………………………
LBS INFORMATION
Registration No:…………………………Class: EMBA / MBA / MMBA
INFORMATION (Please tick appropriately)
Total Number of People on this Trip:
Self Alone
Self with Spouse
Payment by: Individual
Company
Has payment for this seminar been made?
Mode of Payment: Cheque
Self with Spouse & Child
Cash
Yes
No
Direct to LBS Bank Account
This application shall only become valid with the payment of a non-refundable Commitment
Fee of $600 per participant. Spouse & minors are required to pay the commitment fee as well.
Cheque: All cheque payments and deposits should be made payable to Lagos Business School.
Please state your full name as depositor for ease of tracking and send your payment slip
information to Mr. Amaefula Charles, 08033259277 or camaefula@lbs.edu.ng
LBS Bank Account:
Name of Account: Lagos Business School
Bank Account: Standard Chartered Bank Plc.
Bank Account Number; 00100001100 (USD Dom account)
PLEASE COMPLETE THIS APPLICATION FORM AND SUBMIT IT TO ANY OF THE FOLLOWING
ADMINISTRATORS:
IFY CHUKWUKELU
ichukwukelu@lbs.edu.ng
IKEOGLI ADEYOYIN
iadeyoyin@lbs.edu.ng
DIANABASI AKPAINYANG
dakpainyang@lbs.edu.ng
IBRC/LBS RELEASE AND ASSUMPTION OF RISK
I, being of legal age, do hereby agree and promise the following for and in consideration of
my participation in a trip to United States and all activities related thereto:
I have volunteered to travel to United States for the purpose of participation in this program. I
understand that it will be necessary to travel by public and/or private lodging; and to dine at
public and/or private facilities.
I agree and acknowledge that participation in this trip and its related activities is of my own
free will. While I realize that I may participate in certain activities, which may promote and
enhance the image and reputation of the University of Wisconsin – System and Pan-African
University. I acknowledge that I am acting neither as an employee nor agent of the State of
Wisconsin, the Board of Regents, UW-Platteville, or any of their respective officers, employees,
or agents.
I further acknowledge that in the course of the performance of any of the activities, which I
have voluntarily assumed to perform during the trip, I expose myself to risks, known and
unknown, of property damage or loss, as well as personal injury that could be painful,
permanently disfiguring or debilitating and fatal. I fully assume theses risks, which include, but
are not limited to, the risks associated with air and ground travel.
I FOR MYSELF, MY HEIRS, EXECUTORS, ADMINISTRATORS, AND ASSIGNS AGREE TO RELEASE,
WAIVE, DISCHARGE, AND RELINQUISH AND TO HOLD HARMLESS THE STATE OF WISCONSIN, THE
BOARD OF REGENTS, UW-PLATTEVILLE, THE UW-PLATTEVILLE INTERNATIONAL BUSINESS RESOURCE
CENTER, PAN AFRICA UNIVERSITY, AND THE U.S. DEPARTMENT OF EDUCATION OR THEIR
RESPECTIVE OFFICER, EMPLOYEES, OR AGENTS FROM AND AGAINST ALL CLAIMS AND CAUSES
OF ACTION WHICH MAY ARISE FROM MY PARTICIPATION IN THE TRIP AND ITS RELATED
ACTIVITIES OR FROM BY REASON OF NEGLIGENCE OF ANYONE ORGANIZING OR
PARTICIPATING IN THE TRIP OR OTHERWISE, AND AGREE THAT UNDER NO CIRCUMSTANCES WILL
I OR ANYONE CLAIMING THROUGH ME, PROSECUTE OR PRESENT ANY CLAIMS FOR PERSONAL
OR BODILY INJURY, PROPERTY DAMAGE, OR LOSS OR WRONGFUL DEATH AGAINST THE STATE
OF WISCONSIN, THE BOARD OF REGENTS, UW-PLATTEVILLE, THE UW-PLATTEVILLE INTERNATIONAL
BUSINESS RESOURCE CENTER, LAGOS BUSINESS SCHOOL PAN-AFRICAN UNIVERSITY, THEIR
EMPLOYEES OR OFFICIALS, AND THE U.S. DEPARTMENT OF EDUCATION OR THEIR RESPECTIVE
OFFICER, EMPLOYEES, OR AGENTS.
I, for myself and any others claiming through me, accept full responsibility for safety and
expenses, and assume the complete risk of any injury to myself or my property, which may
arise out of or in the course of my participation in this trip.
Print Name:____________________________________________________________
Signature: _____________________________ Date: _________________________
Witness: _______________________________________________________________
Address: _______________________________________________________________
Signature: _____________________________
Date: ________________________