APPLICATION FORM
PERSONAL DETAILS
Name:
Age:
Company:
Address:
Phone: Fax:
Email: Mobile:
Years experience in public relations or a related field:
I wish to be a mentee / mentor [please circle]
I have/have not previously been involved in a mentor/mentee relationship within the PRIA or another organisation
If you have been involved in a mentor/mentee relationship, briefly describe with whom and when
WORK HISTORY
Current position held:
Reporting to:
Responsibilities:
Brief list of previous employers, position and responsibilities:
GENERAL
1) Why you want to be part of the program (please circle as many as appropriate):
Mentee Mentor
a) Career move/ development outside of current area a) Career development
b) Career development in current area b) To ‘give back’ to the industry
c) Career guidance c) Mentoring experience
d) Skill development d) Help someone unlock their potential
e) Someone to confide in
2) Mentee: Is there a specific industry you would seek your Mentor to be associated with or type of role/background, you would wish your Mentor to have experience in?
3) How long do you wish to take part in this program:
a) three months
b) six months
c) as long as the relationship requires
4) Are there any specific times or days that suit you best to meet with your Mentee/Mentor?
5) How would you like to be contacted by your mentor/mentee?
3) Mentees: What specific skills/experience are you looking for in your mentor?
Mentors: What specific skills/experience can you offer?
- career move in-house to consultancy or vice versa
- internal communications
- community relations
- government relations
- consumer PR
- media relations
- consultancy experience
- in-house experience
- other______
4) Would you like to be contacted by the PRIA Mentoring Committee to ensure that you are happy with how your relationship with your mentor/mentee is progressing?
SIGNATURE: DATE:
Please return this form to PRIA NSW by the following methods:
Email: , fax: 02) 9247 6964 or post: c/ PRIA NSW, Level 3, 66 King Street, Sydney NSW 2000