Name:

Address:

City: State: Zip:

E-mail: Cell #:

Major: Minor: G.P.A

Did you watch the video at www.liebowitzentrepreneurprogram.org? Yes ---------No

Do you want to work for yourself one day and why? Yes--No

Are you willing to work some weekends to learn the fine points of being an Entrepreneur? Yes--No

Do you consider yourself a hard worker? Yes--No

Why should I accept you into the program?