Fortune/U.S. State Department
Global Women’s Mentoring Partnership
Application Form 2016
- Name: ______
(First name) (Middle name) (Last name)
B. City and Country of Birth: ______
C.Date of Birth written in full: ______
(Month) (Day) (Year)
D.Citizenship: ______
Passport no: ______
Date of issue: ______
Date of expiration: ______
E. Special considerations, such as allergies, medical and physical challenges, dietary preferences:
F.Do you smoke? Yes ( ) No ( )
G. Business address, telephone and fax numbers:
H.E-mail address:
I.Home address and telephone:
J.Preferred Mailing Address: Business ( ) Home ( )
K.Languages:
1) Native Language:
2) English Proficiency: (5 point FSI scale)
Speaking:
Comprehension:
Written:
L.Do you have strong English skills to enable you to contribute actively in a U.S. workplace—e.g. participating in group discussions, interviews, conversations, etc.?
M.Present Position: (please include exact title, length of time in present position, and description of the candidate’s primary responsibilities)
N. Full Name of Company or Institution
O. Brief Description of Company/Institution: (Please include type of industry, number of employees, annual budget, etc.)
P. How many years of professional experience do you currently have in your industry?
Q. Have you ever had a mentor or a mentee? If so, please explain the mentor/mentee relationship and the key outcomes of the experience.
R. Please list your publications (if applicable):
S. Please list any professional awards or recognitionthat you have received:
T. Please list yourmemberships in local, national or internationalprofessional organizations, associations or clubs:
U. Previous Travel: (Please note if grantee has ever traveled on a U.S. Government program)
Travel to the United States
Dates:
Places Visited:
Sponsorship/Purpose of Visit:
Dates:
Places Visited:
Sponsorship/Purpose of Visit:
V. Educational Background: (List highest degree first. Include significant training programs.)
Dates:
Degree/Certificate:
Institutions:
Field of Specialization:
Dates:
Degree/Certificate:
Institutions:
Field of Specialization:
Dates:
Degree/Certificate:
Institutions:
Field of Specialization:
W.Other Interests: (Sports, Hobbies, Volunteer Activities)
X.Some mentors invite their mentees to stay at their homes during the mentorship. Would you be comfortable with this option?
Part II
1. What are your strengths as a leader?
2. What are your challenges or weaknesses as a leader?
3. What are your top three goals that you would like to address while working with your mentor(s)?
4. Explain how you currently work to empower women and adolescent girls in your community, and how you would expand your reach after participating in the program.
5. What do you hope to gain from an intensive mentorship with a top U.S. female executive?
6. What are you doing now in your profession and what have you done in the past, that make you a good candidate for the program?
7. How did you know about the program?
8. Additional information you would like to include about yourself (optional):
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