Professional Mentoring Program Application Question Title * 1. What is your contact information? Name Current Employer Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number OK Question Title * 2. What is the address of your current place of employment? OK Question Title * 3. Is your place of employment a member of the Lake Champlain Regional Chamber of Commerce? Yes No OK Question Title * 4. Describe your current position: OK 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)) OK Question Title * 6. Employment History: (Please list relevant employment history including title/responsibility for each employer) OK Question Title * 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) OK Question Title * 8. Please describe your perfect mentor. What qualities, experience, or skills are you looking for in a mentor and how would that benefit you? OK Question Title * 9. What do you hope to gain from a professional mentoring relationship? OK Question Title * 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. OK Question Title * 11. Please list two references below: (Please include their name and affiliation as well as their phone number and email address) OK 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. OK 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. OK Question Title * 12. Please sign and date: OK DONE