WiM-Virginia Mentoring Program Application
To be completed by individuals seeking to participate in the WiM-Virginia Mentoring Program. All application information will be treated confidentially and used only for program purposes. A resume or bio is recommended but not required. By submitting this form, you acknowledge that you have read the Mentoring Program Outline and agree to the guidelines and responsibilities.
By submitting this application, I confirm that I have read and understand the Mentee requirements of the WiM Virginia Mentoring Program and agree to fully commit to its expectations. I also confirm that my company/employer fully supports my participation in this program.
I agree
Mentor/Mentee Information
Name
*
First Name
Last Name
Title
*
Company Email
*
example@example.com
Personal Email
*
example@example.com
Work Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Information
Company Name:
*
Number of Employees
Number of Direct Reports
Please answer each question below:
I would like to be considered for the following:
*
Mentor
Mentee
Both
1. What are you hoping to obtain from this mentoring relationship:
*
3. What are your most effective soft skills or leadership strengths. Select the top 3-5 that best represent you:
*
Work Ethic
Communication
Self-Confidence
Positive Attitude
Flexibility
Organization
Emotional Awareness
Initiative
Time Management
Negotiation
Innovation
Leadership
Teamwork
Accountability
Self-Motivation
Stress Management
Cultural Fitness
Ability to Network
Self-Management
Decision-Making
Other
4. What characteristics are you looking for in a Mentor/Mentee?
*
Example: engineer, from a large company, woman mentor preferred, Northern VA region, etc.
5. Are you aware of any constraints that would prevent you from working with a Mentor/Mentee in a particular company or industry?
*
Example: Competitors, Vendors, Subsidiaries, etc.
6. Please provide any additional information that you feel will assist the Mentorship Committee in matching you with a Mentor/Mentee:
*
7. Have you previously been in a mentoring relationship?
*
YES - in an informal (ad-hoc) way
YES - in a formal way (structured program)
No
8. List any noteworthy professional accomplishments that you would like to share:
9. Please provide link to your LinkedIn profile:
A resume or bio is recommended but not required, please add here:
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