WiM-Virginia Mentee Application Form
To be completed by the Mentorship Program Applicant. All application information will be treated confidentially and used only for program purposes. A resume is to accompany this application.
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:
*
3. List two adjectives that you feel most describe you:
*
4. List and elaborate on what you feel are your most effective leadership skills:
*
5. List and elaborate on what you feel are your greatest opportunities for growth:
*
6. List and elaborate on what you feel are your most noteworthy professional accomplishments:
*
7. Describe a specific professional or project goal that you believe could be positively impacted through participation in the WiM Mentorship Program. How will you measure your level of success at the end of the program in achieving this goal?
*
8. What impediments to successful participation can you envision at this time?
*
9. What are the characteristics that you are looking for in a Mentor?
*
10. What characteristics would the ideal Mentor possess to help you achieve your personal and professional goals?
*
11. Are you aware of any constraints that would prevent you from working with a Mentor in a particular company or industry?
*
Example: Competitors, Vendors, Subsidiaries, etc.
12. What, if any, constraints do you have that would limit your travel for face to face meetings?
*
13. Please provide any additional information that you feel will assist the Mentoring Committee in evaluating your application:
*
Please attach your resume here:
*
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