2021-2023 Global Leadership Mentoring Community (GLMC) Application

Question Title

* 1. Dear prospective mentor or mentee, please complete the following:

Name: *

Employer:

City/Town:

State/Province:

ZIP/Postal Code:

Country: *

Email Address: *

Alternate email:

Question Title

* 2. Are you interested in being a Mentor or Mentee (or not sure)?

Mentor

Mentee

Not sure

Other (please specify)

Question Title

* 3. What is your STTI Chapter? Example: Gamma Eta Chapter, Samford University, Birmingham, Alabama, USA

Question Title

* 4. Name, credentials & primary position: Please include credentials, position, institution, City/State/Country.
Example: Ellen Buckner PhD, RN, CNE, AE-C, FNAP, Professor of Nursing, Samford University, Birmingham, AL, USA.

Question Title

* 5. What is your area of work? Check all that apply.

Education

Practice

Research

Administration

Retired

Other (please specify)

Question Title

* 6. Why you would like to participate as a Global Leadership Mentee or Mentor?

Question Title

* 7. What are your current leadership activities, including in your Sigma chapter?

Please send a digital photo and a 2-page Biosketch (Curriculum Vita, resume, or short summary) to ebbuckner@gmail.com

Thank you!

Question Title

* 1. Dear prospective mentor or mentee, please complete the following:

Question Title

* 2. Are you interested in being a Mentor or Mentee (or not sure)?

Question Title

* 3. What is your STTI Chapter? Example: Gamma Eta Chapter, Samford University, Birmingham, Alabama, USA

Question Title

* 4. Name, credentials & primary position: Please include credentials, position, institution, City/State/Country. Example: Ellen Buckner PhD, RN, CNE, AE-C, FNAP, Professor of Nursing, Samford University, Birmingham, AL, USA.

Question Title

* 5. What is your area of work? Check all that apply.

Question Title

* 6. Why you would like to participate as a Global Leadership Mentee or Mentor?

Question Title

* 7. What are your current leadership activities, including in your Sigma chapter?

* 4. Name, credentials & primary position: Please include credentials, position, institution, City/State/Country.
Example: Ellen Buckner PhD, RN, CNE, AE-C, FNAP, Professor of Nursing, Samford University, Birmingham, AL, USA.