Mentee Application

Name(required)

Prefer To Be Called(required)

Title

Ms.

Mr.

Mrs.

Dr.

Convenient Areas To Meet Your Mentor(required)

Home Phone

Mobile Phone(required)

Email(required)

Street Adress

City

State

Zip

Emergency Contact

Emergency Number

Relationship To You

Employer

Industry

Position

Highest Level of Education Obtained

High School Diploma/GED

Associate/Vocational Degree

Bachelor's Degree

Graduate Degree

Doctorate

Other

Please tell us what you feel are your strengths and weaknesses.

What do you hope to accomplish with this mentorship experience?(required)

OPTIONAL: To further assist us in selecting the best match for you and your goals, we invite you to include a personal statement telling us where you've been and where you want to go, personally and professionally.

SIGNATURE OF AGREEMENT

I understand that the NAAAP-Phoenix Mentorship Program is a voluntary program whose success depends on the level of participation of both Mentor and Mentee.  I understand that while the NAAAP-Phoenix Mentorship Committee will make every effort to match me with an appropriate Mentee, the Mentorship Committee is not responsible for the performance of my Mentee, nor can the Mentorship Committee guarantee a match.

I understand that any breach of confidentiality between my Mentee and me will be grounds for dismissal from the Mentorship Program.  I agree to inform my Mentee and the Mentorship Committee should I no longer be able to participate as a Mentor.

I verify that the information on this application is true to the best of my knowledge.  I understand that I will be required to go through an orientation before I can participate in the Mentorship Program.

 

Applicant's Name(required)

Date

Submit

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