Mentor Application

MENTOR APPLICATION
P.O. Box 360171

Brooklyn, NY

11236-0171

631-954-1920 • 347-523-2196

www.mipoinc.org • info@mipoinc.org
PART I – Personal Information
Date:

MonthDayYear
Date
First
Last
Address:
Cell:
Alternate:
Email address:
example@example.com
Emergency contact name:
Relationship:
Emergency contact numbers:
What languages other than English do you speak?
What is the highest level of education you have achieved:
What is your racial Background?
What is your religious affiliation?
PART II – Employment Information
Are you currently employed?

YesNo
What is your occupation?
Name of employer:
What is your position?
Business Address:
Work phone:
How long have you been in that position?
Yrs.
Mths.
Describe your current and prior professional experience and responsibilities
PART III – Mentoring
All mentors must undergo a comprehensive screening process. The screening includes completion of an application, interview, personal and professional reference checks and criminal background checks. Other checks, such as child abuse and sexual offender registries and motor vehicle records, may also be used.
Have you been fingerprinted in New York State?

YesNo
Have you ever been convicted of child abuse or child sexual abuse?

NoYes
Have you ever been charged or convicted of any misdemeanor or felony in this state or any elsewhere?

NoYes
Have you been a mentor before?

YesNo
If yes, When?
How long?
Why do you want to be a mentor?
Is there a particular area / aspect of the profession you would most like to work on with a Mentee? If so, please provide details:
Mentoring a young person is a big responsibility and can change the lives of both the Mentor and the Mentee. What do you hope to gain from the experience? What do you hope the Mentee will gain?
What other support can and will you offer to the Mentoring program? i.e. workshop presentation (specify topic), venue, food, etc.
PART IV – Mentor Responsibilities
It is recommended that all mentors attend at least one MIPO Mentor/Mentee workshop per quarter. Will it be possible for you to provide this time to the program?

YesNo
It is recommended that at least 2 hours each month be set aside for interaction specific to the mentoring relationship. Will it be possible for you to provide this time to the program?

YesNo
If you answered no in the previous question, please indicate the amount of time (hours) you could commit in a 12-month period:
It is recommended that all mentors coordinate and host at least one job shadowing session. Will it be possible for you to provide this time to the program?

YesNo
Do you have any hobbies or special skills that you think will benefit MIPO's Mentees?
PART V - Reference

Please provide two references below (one personal and one professional
Reference # 1 - Name

First NameLast Name
Phone Number

Area CodePhone Number
E mail:
example@example.com
Reference #2 - Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
PART VI - Additional Information
Are you currently a MIPO, Inc. member?

YesNo
How did you hear about MIPO Inc.' s Mentoring Program?
PART VII - Acknowledgement
I, {first}, agree to serve as an active Board Member of MIPO, Inc. and I will volunteer sufficient time and resources to help achieve its mission. I will be an ambassador of MIPO, Inc. and will fulfill my fiduciary responsibilities to the best of my abilities.
Print Name
Signature

Clear
Date

MonthDayYear
Date
Thank you for your interest in serving as a Mentor. The Mentor Program Coordinator will review your application and contact you for an interview.
For office use only
Application reviewed on:

MonthDayYear
Date
Application accepted on:

MonthDayYear
Date
Date applicant was contacted:

MonthDayYear
Date
Interview date:

MonthDayYear
Date
Action taken by the board:
Should be Empty:

MENTOR APPLICATION

PART I – Personal Information

PART II – Employment Information

PART III – Mentoring

PART IV – Mentor Responsibilities

PART V - Reference

PART VI - Additional Information

PART VII - Acknowledgement

For office use only