Greater Kansas City Chamber of Commerce S

2013 Application for the Greater Kansas City Chamber of Commerce’s Access for Entrepreneurs Program

The Access for Entrepreneurs program of the Greater Kansas City Chamber of Commerce represents a cross-section of the community’s startup and entrepreneurial community. This program includes active participation in 11 monthly luncheon meetings with exposure to community leaders and issues. Criteria for acceptance include the potential for scalable success and desire for more engagement and involvement in civic and entrepreneurial leadership.

Participation and time commitment: Program participants are strongly encouraged to attend monthly luncheons from February 2013 through December 2013. Participants who repeatedly fail to meet the attendance expectations will be asked to withdraw from the program. The program is complimentary for Greater Kansas City Chamber of Commerce members; it is $350 for non-members - The KC Chamber will attempt to secure a sponsorship upon request.

______Name of applicant and Date

I plan to be fully engaged and participate in the Access for Entrepreneurs Program and fully understand the attendance requirements outlined above.

The completed application is due to the following address by the end of business Friday, January 25, 2013. Please email your completed application to [email protected] or by mail to the following:

Access for Entrepreneurs Program Greater Kansas City Chamber of Commerce 30 West Pershing Road, Suite 301 Kansas City, MO 64108

Next Steps: Each applicant will be notified of the selection results by January 31, 2013. For more information about the program and its application process, please contact Christine Murray, Director of Entrepreneurship at the Greater Kansas City Chamber of Commerce at (816) 374-5455 or [email protected]. APPLICANT First Name: Last Name: Preferred Name: Home Address: City: State: ZIP Code: Cell Phone: E-mail Address:

Race/ethnicity: American Indian or Alaska Native Asian or Pacific Islander Black, not of Hispanic origin Hispanic or Latino White, not of Hispanic origin Other (please specify): Prefer not to respond

Gender: Female Male

BUSINESS INFORMATION Company Name: Company Website: Current Title: Business Address: City: State: ZIP Code: Phone: Twitter @ E-mail Address:

What is the nature of your startup organization?

Please define your market area – local, national, international?

PREVIOUS EMPLOYMENT (Or attached current copy of resume) Employer: City: State: Dates Title: Employed:

Employer: City: State: Dates Title: Employed:

Is it likely that you relocate out of Kansas City within the next two years? Yes No

How many days per month does your work require you to travel? 1. Briefly describe your current job responsibilities or activities what are you trying to accomplish?

2. What’s your organizations most significant contribution or achievement to date?

3. How would you describe your leadership role within your current organization?

4. List your most recent professional affiliations in which you have been active.

HONORS AND AWARDS List any significant honors, awards, or prizes you have received for professional, community, or civic achievement.

VIEWS AND OPINIONS One of the goals of the Access for Entrepreneurs is to build a network of startup leaders who can enhance problem- solving and leadership abilities through shared perspective and collaboration. Please provide a brief summary of your views on the following issues, limit your total response to all three questions to one page.

1. What do you feel are three problems or opportunities facing greater Kansas City entrepreneurial community today? Why?

2. What skills or knowledge would you like more information regarding (coding, leadership, business development, etc)?

3. What impact could your company’s participation have on the community?