Mentor Questionnaire Question Title * 1. Contact Information Salutation (Mr., Ms., Dr., etc.) 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 Training Question Title * 6. Areas of Experience/ExpertiseOn a scale of 1 to 5 with 1 being inexperienced and 5 being experienced, please tell us how experienced you are with each of the following interest areas. Your response should reflect your confidence and ability to mentor in these areas. Inexperienced Somewhat Inexperienced Neither Inexperienced or Experienced Somewhat Experienced Experienced Building Industry Credibility Building Industry Credibility Inexperienced Building Industry Credibility Somewhat Inexperienced Building Industry Credibility Neither Inexperienced or Experienced Building Industry Credibility Somewhat Experienced Building Industry Credibility Experienced Communication Communication Inexperienced Communication Somewhat Inexperienced Communication Neither Inexperienced or Experienced Communication Somewhat Experienced Communication Experienced Community or Business Development Community or Business Development Inexperienced Community or Business Development Somewhat Inexperienced Community or Business Development Neither Inexperienced or Experienced Community or Business Development Somewhat Experienced Community or Business Development Experienced Corporate Culture Corporate Culture Inexperienced Corporate Culture Somewhat Inexperienced Corporate Culture Neither Inexperienced or Experienced Corporate Culture Somewhat Experienced Corporate Culture Experienced Decision Making Decision Making Inexperienced Decision Making Somewhat Inexperienced Decision Making Neither Inexperienced or Experienced Decision Making Somewhat Experienced Decision Making Experienced Organizational Change Organizational Change Inexperienced Organizational Change Somewhat Inexperienced Organizational Change Neither Inexperienced or Experienced Organizational Change Somewhat Experienced Organizational Change Experienced Networking Networking Inexperienced Networking Somewhat Inexperienced Networking Neither Inexperienced or Experienced Networking Somewhat Experienced Networking Experienced Personal Branding Personal Branding Inexperienced Personal Branding Somewhat Inexperienced Personal Branding Neither Inexperienced or Experienced Personal Branding Somewhat Experienced Personal Branding Experienced Strategic/Tactical Planning Strategic/Tactical Planning Inexperienced Strategic/Tactical Planning Somewhat Inexperienced Strategic/Tactical Planning Neither Inexperienced or Experienced Strategic/Tactical Planning Somewhat Experienced Strategic/Tactical Planning Experienced Team Building Team Building Inexperienced Team Building Somewhat Inexperienced Team Building Neither Inexperienced or Experienced Team Building Somewhat Experienced Team Building Experienced Time Management Time Management Inexperienced Time Management Somewhat Inexperienced Time Management Neither Inexperienced or Experienced Time Management Somewhat Experienced Time Management Experienced Other (please specify) Question Title * 7. If possible, do you want a mentee in the same industry? Yes No Indifferent Question Title * 8. What are your expectations of a mentee? Question Title * 9. What are your expectations as the mentor? Question Title * 10. Personal Information (optional) Hobbies Martial Status Children (names and ages) Question Title * 11. Additional Information (list any additional information the committee may want for matching you with a suitable mentee) Next
