Mentee Questionnaire Question Title * 1. Contact Information First Name Last Name Annotation (Jr., Sr., M.D., etc.) Preferred Name (Matt vs. Matthew) Employer Title Business Address City, State, Zip Business Phone Cell Phone Business Email Personal Email Question Title * 2. Preferred Method of Contact (check all that apply) Business Phone Cell Phone Business Email Personal Email Other (please specify) Question Title * 3. Employment History Employer Title Time Period Employer Title Time Period Employer Title Time Period Question Title * 4. Membership and Positions in Other Organizations Question Title * 5. Education Degree Institution Degree Institution Degree Institution Seminars, conferences and other trainings Question Title * 6. Areas of InterestRank theses areas of interest. We will use this information to help match you with a mentor with experience in these areas. 1 = most interest and 11 = lowest interest. 1 2 3 4 5 6 7 8 9 10 11 Building Industry Credibility 1 2 3 4 5 6 7 8 9 10 11 Communication 1 2 3 4 5 6 7 8 9 10 11 Community or Business Development 1 2 3 4 5 6 7 8 9 10 11 Corporate Culture 1 2 3 4 5 6 7 8 9 10 11 Decision Making 1 2 3 4 5 6 7 8 9 10 11 Organizational Change 1 2 3 4 5 6 7 8 9 10 11 Networking 1 2 3 4 5 6 7 8 9 10 11 Personal Branding 1 2 3 4 5 6 7 8 9 10 11 Strategic/ Tactical Planning 1 2 3 4 5 6 7 8 9 10 11 Team Building 1 2 3 4 5 6 7 8 9 10 11 Time Management Question Title * 7. If possible, do you want a mentor in the same industry? Yes No Indifferent Question Title * 8. What are your expectations as the mentee? Question Title * 9. What are your expectations of your mentor? Question Title * 10. Personal Information (optional) Hobbies Martial Status Children (names and ages) Question Title * 11. Is there anything else you want the Matching Committee to be aware of? Question Title * 12. Please acknowledge the following statement. Yes, I acknowledge there is a $100 program fee for the Mentor Program once a match is made. I will NOT be invoiced until a match is made. Next