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

Name: *

Employer: 

City/Town:

State/Province:

ZIP/Postal Code:

Country: *

Email Address: *

Alternate email: 

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

Mentor

Mentee

Not sure

Other (please specify)

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

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.

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

Education

Practice

Research

Administration

Retired

Other (please specify)

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

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!