Entrepreneurs Society Membership Application First Name: Last Name: Permanent Address: Address (cont.): City: State: Zip: Email: Phone:    Category: Entrepreneur   I have started or intend to launch a new business Target Date: Please Select One Already Launched 2009 2010 2011 2012 2013 2014 2015 2016 Company Name: Industry: Please Select One Acoustics Aerospace and Defense Agriculture & Aquaculture Apparel and Textiles Assistive Technology for the Handicapped Automotive Technology Biotechnology Broadcasting/Cable/Radio Business Services Communication Equipment Computer Hardware Computer Software Consumer Products Consumer Services Diagnostics Display Technology Diversified (Other technology, not listed) Education Electronic Equipment and Components Energy and Natural Resources Environmental Protection Film and Digital Media Financial Services Food Services/Products Health Care Services Health/Medical IT Industrial Equipment Information Technology Internet & Online Services Manufacturing Maritime Materials & Chemicals Medical Devices Nanotechnology Optics and Photonics Pharmaceuticals Plastics Publishing Real Estate/Construction Recreation and Tourism Retailing Robotics and Automation Security & Law Enforcement Semiconductors and Integrated Circuits Sensors Speech Processing and Recognition Telecom/Networking Transportation Wholesaling/Distribution Wireless Communications Company Stage: Please Select One Pre-Seed stage (R&D) Seed stage (Proof of concept) Start up (Ready to Launch) Early stage (Sales under $500,000) Expansion stage (Sales $500,000 to $5,000,000) Late stage (Sales > $5,000,000) Buy-out, IPO Stage (Sales >$25,000,000) URL: Seeking Position  (check all that apply) I would like to join a start-up as a member of the management team. I am seeking an internship.   Paid only   Paid or Non-Paid I am seeking part-time employment while in school. I am seeking full-time employment. Educator   I would like to serve as an educator Mentor   I would like to serve as a pro bono coach to an entrepreneur Firm: Specialties:      School Affiliation: University or College: Please Select One Albertus Magnus College Asnuntuck Capital Community College Central Connecticut State University Eastern Connecticut State University Fairfield University Gateway Community College Housatonic Community College Manchester Community College Middlesex Community College Mitchell College Naugatuck Valley Northwestern CT Norwalk Community College Phoenix Post University Quinebaug Valley Quinnipiac University Rensselaer at Hartford Sacred Heart University Saint Joseph College Southern Connecticut State University Three Rivers Community College Trinity College Tunxis Community College University of Bridgeport University of Connecticut - Hartford University of Connecticut - Stamford University of Connecticut - Storrs University of Connecticut - Waterbury University of Hartford University of New Haven Western Connecticut State Yale Entrepreneurship Institute Yale University - Dept. of Computer Science  Yale University - School of Forestry Yale University - School of Management Yale University - Law School Level:   Graduate Student        Undergraduate Student Major or Concentration: Year of Graduation: Please Select One Already Graduated 2009 2010 2011 2012 2013 2014 2015 2016   Business Adviser: Business Adviser's Email: