Registration Form

NSSTA Women's Caucus

Mentee Registration & Matching Survey
Personal Details & Objective
Name

First NameLast Name
Gender
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:
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?

Other
What Best Describes you
Communication

Please indicate your preferences in the questions below.
How would you prefer to communicate with your mentor?
In addition to the program’s monthly meet up, how often would you prefer to communicate with your mentor?
Please check the time of day you prefer for communicating with your mentor?
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.
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