You have completed 0% of this survey 0% default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. Data for your profile on the attendee list When you have completed the following form, we will include the data and your photo in the event attendee list and event app (both accessible only to the event participants), so other attendees can read about your areas of experience, general interests, and current challenges, and they can then locate you at the event. In this way, we wish to enable effective and targeted networking at Innovation Roundtable® events. We thank you in advance for submitting this short form. It will only take a few minutes. NB: Please make sure to click on SUBMIT at the bottom of the last page. Your data * Please use the same corporate e-mail address at which you have received the invitation to fill in this form. First Name: Last Name: Company Name: Division (optional): Job Title: Corporate E-mail*: (This question is mandatory) In which country are you based? Choose one of the following answers Please choose... Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cabo Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (Democratic Republic of the) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (Democratic People's Republic of) Korea (Republic of) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia (the former Yugoslav Republic of) Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova (Republic of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States of America United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe (This question is mandatory) Your photo Please use my photo on LinkedIn I want to upload my photo Other: Please upload a picture that you would like to have included in the attendee list Please upload at most one file Upload file Title Comment File name Upload file (This question is mandatory) Innovation Roundtable® privacy policy (click here to open) I have read and hereby accept the Innovation Roundtable privacy policy Next Please confirm you want to clear your response? Exit and clear survey