Name *

Title *

Organization *

Type of Organization * CorporationStartupInvestorIncubator/AcceleratorCivic OrgNGOGovernmentEducationR&DCultural Exchange

Mision *

E-Mail *

Phone *

Home Region (The region you would like to represent and lead iTi initiatives.) *

Regional Partners (The regions where you already do business and want to connect with local partners who represent and lead iTi initiatives.) *

Regions of Interest (The regions where you would like to develop business and want to connect with local partners who represent and lead iTi initiatives.) *

Social Impact (Brief descriptor of what specific problem you seek to impact and what kinds of partnerships you are seeking to form through iTi?)) *