WiM-Virginia Mentor Survey
To be completed by Mentors seeking to participate in the WiM-Virginia Mentoring Program to facilitate the matching of Mentors with Mentees. All application information will be treated confidentially and used only for program purposes. A resume or bio is to accompany this survey. By submitting this form, you acknowledge that your company/supervisor approves your participation in the WiM-Virginia Mentoring Program.
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Number of Employees
Number of Direct Reports
Please answer each question below:
1. Please explain what is motivating you to participate in this program:
2. Briefly describe the "corporate culture" of your current company and/or the corporate culture to which you have had the most exposure:
3. List and elaborate on what you feel are your most effective soft skills or leadership strengths:
4. List and elaborate on what you feel are your most noteworthy professional accomplishments:
5. List two adjectives that you feel most describe you:
6. What impediments to successful participation can you envision at this time?
7. What characteristics would the ideal Mentee possess to help you provide maximum value in the Mentoring relationship?
8. Are you aware of any constraints that would prevent you from working with a Mentee in a particular company or industry?
Example: Competitors, Vendors, Subsidiaries, etc.
9. What are some of your leadership and professional growth opportunities?
10. Please provide any additional information that you feel will assist the Mentorship Committee in matching you with a Mentee:
11. Have you previously been in a Mentor in a mentoring relationship?
YES - in an informal (ad-hoc) way
YES - in a formal way (structured program)
12. Describe what your protegee gained in the following areas: Career development, Social/Networking, Leadership/Role Modeling Capability:
Please attach your resume or bio here:
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