Orange Country ASSP Mentor Application

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* 1. Work and Cell Phone

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* 2. Email Address

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* 3. Employer and Position Title

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* 4. Full Name (First and Last)

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* 5. ASSP #

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* 6. Are you willing and able to commit to a mentor program for one year?

Yes

No

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* 7. What mentoring strengths do you possess?

Enthusiasm and respect for safety industry

Positive attitude and positive role model

Willingness to share skills, knowledge, expertise

Can commit at least 1 hour per week to my mentee

I am willing to take personal interest in the mentoring relationship

Value the opinions of others

Set and meet ongoing personal goals

Other (please specify)

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* 8. Have you ever served as a mentor?

Yes

No

If yes, explain

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* 9. Can you attend September 18, 2019 Mentor Mixer?

Yes

No

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* 10. Briefly Describe Education and Industry Experience

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* 11. Professional Certifications

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* 12. List3 reasons why you want to be a mentor?

Reason 1

Reason 2

Reason 3