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.
Contact Information
Name
*
First Name
Last Name
Title
*
Company Name
*
Email
*
example@example.com
Work Phone
*
Please enter a valid phone number.
Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Information
Industry:
*
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)
No
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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