SCALE: Mentor Application

ChicagoMSDC SCALE (Supplier Capacity & Leadership Engagement) Mentorship Program
Program Term: Six-month cohort cycle
Purpose: This application is used to determine mentor eligibility, capacity, alignment, and readiness to support a participating MBE through the SCALE program.
Instructions: Please complete all sections. ChicagoMSDC may request additional
documentation, conduct an interview, and complete due diligence before approving mentor participation. Submission of this application does not guarantee selection as a SCALE Mentor.
Section 1: Mentor Form Information
Legal Business Name
Doing Business As (if applicable)
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Primary NAICS/Industry
What Year was the Company Founded?
Annual Gross Revenue
Number of Full-Time Employees
NMSDC Certification Status

Other
Section 2: Primary Mentor Contact
Designated Lead Mentor Name

First NameLast Name
Title
Email
example@example.com
Mobile #
Please enter a valid phone number.Format: (000) 000-0000.
Years with the firm
Relevant Mentoring, Supplier Development, or Procurement Experience
Section 3: Eligibility Confirmation
Please confirm that your firm meets the following mentor eligibility criteria:
Section 4: Mentor Capacity and Expertise
Briefly describe your firm’s core capabilities, industries served, and primary customer segments.
Identify the areas where your firm can provide the strongest mentoring support.

Other
Describe prior experience mentoring, advising, subcontracting with, or developing diverse suppliers or growth-stage businesses.
Section 5: Matching, Due Diligence, and Independence
Are there any industries, services, or company profiles that would be the best fit for your firm’s mentoring support?
Please disclose any current or potential conflicts of interest with prospective Mentee firms, including ownership, family, employment, financial, subcontracting, or competitive relationships.
Please confirm your firm will conduct due diligence on any potential Mentee before final match approval.
Please explain:
Section 6: Program Commitments
By applying to serve as a SCALE Mentor, the applicant agrees to the following commitments if selected:
Section 7: Development Plan Alignment
What measurable outcomes would your firm be prepared to help a Mentee pursue during the six-month program cycle?

Other
Please describe how your firm would approach developing and tracking milestones with a Mentee.
Section 8: Required Attestations

Please initial each statement:
I certify that the information provided in this application is true and complete to the best of my knowledge.
I certify that my firm is in good standing with the State of Illinois and ChicagoMSDC.
I certify that my firm is not debarred or suspended.
I understand that ChicagoMSDC may verify eligibility, conduct interviews, and request supporting documentation.
I understand that final mentor approval and matching are subject to ChicagoMSDC review and approval.
Section 9: Submission Checklist
Please ensure you have completed all of the following:
Section 10: Required Uploads
Capability Statement or Company Overview Document

Cancelof
Bio or Resume

Cancelof
Applicant Certification and Signature
Name

First NameLast Name
Title
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
By signing below, I certify that I am authorized to submit this application on behalf of the mentor firm and that the information provided is accurate and complete.
Should be Empty:

Section 1: Mentor Form Information

Section 2: Primary Mentor Contact

Section 3: Eligibility Confirmation

Section 4: Mentor Capacity and Expertise

Section 5: Matching, Due Diligence, and Independence

Section 6: Program Commitments

Section 7: Development Plan Alignment

Section 8: Required Attestations

Section 9: Submission Checklist

Section 10: Required Uploads

Applicant Certification and Signature