Mentor Application Form

MENTOR APPLICATION FORM Name:

Job Title/Company:

Phone:

E-mail:

Number of years in business:

Age: (optional)

Directions: Please answer the questions below and attach your current resume or bio. Return both items via email to Lynn Zalokar at [email protected]. Please verify receipt of your application with Lynn by calling her at: (212) 221-7969. •

I understand that this program requires me to commit to spending one (1) hour per month (from January 2010 to December 2010) with my mentee and I agree to this. Yes [ ] No [ ]

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I understand that I may not be able to be paired exactly to match my request below however I still would like to participate as a mentor. Yes [ ] No [ ]

Check box #1 and/or box #2 (you can do both). 1. [ ] I am applying as a mentor. 2. [ ] I am applying as a Reverse Mentoring Applicant. I would like to gain technical expertise and a different perspective from a more junior member. As a mentor please explain the top two things you can bring to this program 1. 2. Describe yourself in three words, describe your ideal mentee in three words:

REQUEST FOR MENTORING PARTNER: Please number the top four areas 1-4 (with 1 being the highest) where you can provide insight/leadership to a mentee. Do not mark more than four (4) boxes. Do not mark 4 boxes in each column! Businesses Advertising Broadcast/Cable Client/Brand Management Corp. Communications/P.R. Digital/Interactive Marketing/Marketing Services Publishing Sales Other ____________________

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Specialties Brand Experience [ Creative [ Digital [ H.R./Talent Mgmt. [ Integrated Media [ New Bus. Development [ Relationship Mktg. [ Strategic Planning [ Sales/Acct. Mgmt. [ Other ______________ [

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Skills Commercial Creativity Career Change/Career Development Diversity/Multi-Cultural Networking Talent Leadership/Development Selling, Negotiation Other___________________________

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If you have any questions either about the program or the application, please contact one of the following committee members:  Terry Yoffe: (212) 876-8166 or [email protected]  Beth Warren: (917) 547-1508, [email protected] *Please note: Incomplete applications cannot be processed. All participants must be current AWNY members. If you are interested in becoming an AWNY member please go to www.awny.org and sign up.

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Application Deadline: November 16, 2009  Program Begins January 2010