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* 1. Are you a mentor or protege?

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* 2. Name:

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* 3. What is your PNCWA Membership #? (Enter "NA" if not a member or do not know #)

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* 4. Email:

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* 5. Phone:

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* 6. Company/Agency/School:

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* 7. Position/Major and Degree:

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* 8. In what city or region do you work or go to school?

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* 9. How many years of professional experience do you have?

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* 10. What (has been)/(will be) your primary career track?

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* 11. What major areas of work are you interested in (select all that apply)?

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* 12. Please describe your experience with PNCWA (choose all that apply).

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* 13. If you know who you would like for your mentor or protege, please specify.

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* 14. Is the person indicated in Question #12 the same person you were paired with last year, if applicable?

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* 15. Do you mind if your mentoring team member is long-distance?

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* 16. How would you prefer to communicate with your mentoring team member?

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* 17. Can you commit to a minimum of 6 hr over the course of the year?

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