Registration Form

NSSTA Women's Caucus

Mentee Registration & Matching Survey
Personal Details & Objective
Name*

First NameLast Name
Gender*

Woman+Man
Company*
Years in the Industry*
E-mail*
Contact Phone (Business Hours)*

Area CodePhone Number
Briefly describe you Professional Experience:
What is the number one challenge you are facing that a mentor might be able to help you tackle?
Getting to Know You

Research indicates that mentorship pairs are more successful when demographics are considered. Complete only what you are comfortable sharing.
Age
Select the following that describe you:

No kids / Fur babies!Kids at home (married)Kids at home (single)No Kids / No Pets: I like my Space!Working full-timeWorking part-time
Where did you grow up:
Do you have any siblings?
What are two topics you could talk for 30 minutes about with absolutely no preparation?
What are your personal interests and hobbies outside of work?

CookingEducationElectronic GamesFilmFinanceLeisure ReadingMusicPoliticsSportsTravelArtsVolunteeringOther
What Best Describes you

OutgoingBusiness-orientedConstructiveEmpatheticFunnyLivelyIntuitivePassionateReservedReflectiveVibrant
Communication

Please indicate your preferences in the questions below.
How would you prefer to communicate with your mentor?

E-mailPhoneZoomIn person (if feasible)Combination of the above
In addition to the program’s monthly meet up, how often would you prefer to communicate with your mentor?

Once a weekBi-weeklyOnce a month
Please check the time of day you prefer for communicating with your mentor?

MorningAfternoonEveningCombination depending on schedule
Topics of Professional Interest
Briefly describe your business objectives for the coming year:
Primary Specialty*
(Plaintiff/Defense, Liability, Work Comp, MSP Compliance, Trusts, etc.)
Please select up to three areas that you would most like to develop.

Work Life BalanceBusiness EtiquetteCommunicationsBuilding your Business from the Ground UpGovernment BenefitsSynergy between Consultants and Support Staff – Building an Effective TeamTechnology and social media in Today’s WorldNegotiation and Conflict ManagementExisting in Today’s Corporate WorldImage and Impact
Please use the space below to list any other factors that you consider important when being matched with a mentor.
E-Signature Name*
Date*

MonthDayYear
Date
After submitting your registration, the NSSTA Women's Caucus will review your application and contact you with any additional questions. Thank you for your interest in the joining the NSSTA Women's Caucus Mentorship Program!
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NSSTA Women's Caucus

Personal Details & Objective

Getting to Know You

Communication

Topics of Professional Interest