Professional Mentoring Program Application

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* 1. What is your contact information?

Name

Current Employer

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. What is the address of your current place of employment?

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* 3. Is your place of employment a member of the Lake Champlain Regional Chamber of Commerce?

Yes

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* 4. Describe your current position:

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* 5. Education and Specialized Training Programs: (Please use the space below to list the name and location of organization/schools attended, and degree/major (if applicable))

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* 6. Employment History: (Please list relevant employment history including title/responsibility for each employer)

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* 7. Please list, in order of importance to you, community, civic, professional, business, religious, social, athletic, and other organizations you have been involved with in the last five years: (Please include organization names, dates, and office/position held)

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* 8. Please describe your perfect mentor. What qualities, experience, or skills are you looking for in a mentor and how would that benefit you?

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* 9. What do you hope to gain from a professional mentoring relationship?

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* 10. If you have identified an individual(s) in the community that you could learn from as a mentor, please list their name and affiliation below. Please feel free to explain why you feel they would be a good mentor for you.

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* 11. Please list two references below: (Please include their name and affiliation as well as their phone number and email address)

Tuition/responsibilities: Tuition is due upon acceptance and must be received prior to the start of the program. Tuition is $50 for employees of LCRCC members and $125 for non-members. Upon notification of acceptance into the program, you may mail a check for the amount due or contact the Chamber at (802)-863-3489 to pay by credit. No refunds will be issued.

All applications are subject to confidential evaluation and applications accepted into the program will be paired with a mentor based on the evaluation of their application and interests. All participants will be notified of acceptance or non-acceptance. By signing below, you agree to pay the tuition fee if accepted into the program.

Question Title

* 1. What is your contact information?

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* 2. What is the address of your current place of employment?

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* 3. Is your place of employment a member of the Lake Champlain Regional Chamber of Commerce?

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* 4. Describe your current position:

Question Title

* 5. Education and Specialized Training Programs: (Please use the space below to list the name and location of organization/schools attended, and degree/major (if applicable))

Question Title

* 6. Employment History: (Please list relevant employment history including title/responsibility for each employer)

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* 7. Please list, in order of importance to you, community, civic, professional, business, religious, social, athletic, and other organizations you have been involved with in the last five years: (Please include organization names, dates, and office/position held)

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* 8. Please describe your perfect mentor. What qualities, experience, or skills are you looking for in a mentor and how would that benefit you?

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* 9. What do you hope to gain from a professional mentoring relationship?

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* 10. If you have identified an individual(s) in the community that you could learn from as a mentor, please list their name and affiliation below. Please feel free to explain why you feel they would be a good mentor for you.

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* 11. Please list two references below: (Please include their name and affiliation as well as their phone number and email address)

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* 12. Please sign and date: