FORTUNE/U.S. State Department
International Mentoring Partnership
Nomination Form 2012
A. Name: ______
(First name) (Middle name) (Last name)
B.City and Country of Birth: ______
C. Date of Birth written in full: ______
(Month) (Day) (Year)
D.Passport no: ______
Date of issue: ______
Date of expiration: ______
E. Marital Status:______
F. Citizenship: ______
G. Special considerations, such as allergies, medical and physical challenges, dietary preferences:
H.Does nominee smoke? Yes ( ) No ( )
I. Business address, telephone and fax numbers:
J.E-mail address:
K. Home address and telephone:
L. Preferred Mailing Address: Business ( ) Home ( )
M. Languages:
1) Native Language:
2) English Proficiency: (5 point FSI scale)
Speaking:
Comprehension:
Written:
N. Present Position: (exact title, starting date, and brief description of role in company)
O. Full Name of Company or Institution
P. Brief Description of Company/Institution: (Please include type of industry, number of employees, annual budget, etc.)
Q. Publications (if any):
R. Professional memberships in local, national or international professional organizations or associations or clubs:
S. Previous Travel to the United States: (Please note if grantee has ever traveled on a U.S. Government program)
Dates:
Places Visited:
Sponsorship/Purpose of Visit:
- Other Travel Abroad
Dates:
City and Country:
Principal Purpose of Visit:
Dates:
City and Country:
Principal Purpose of Visit:
Dates:
City and Country:
Principal Purpose of Visit:
U. Educational Background: (List highest degree first. Include significant training programs.)
Dates:
Degree/Certificate:
Institutions:
Field of Specialization:
- Other Interests: (Sports, Hobbies, Volunteer Activities)
- Would the nominee be comfortable with a homestay situation (i.e. staying in the home of the mentor)?
Fortune mentors and their companies generously invest a great amount of time, effort, and money in hosting participants for this program and ECA wishes to ensure that all candidates are outstanding representatives of their countries and their own firms. Once candidates are selected, they will be expected to make a firm commitment to the program. Please elaborate below your reasons for nominating this candidate.
Reasons for Nomination:
1. What does the candidate hope to gain from an intensive mentorship with a top U.S. female business executive?
2. What is the candidate doing now in her profession, and what has the candidate done in the past, that make you consider her a good candidate for the program?
3.Does the candidate have sufficient English skills to enable her to contribute actively in a U.S. workplace—e.g. participating in group discussions, interviews, conversations, etc.?
4. Was the candidate recommended to post by a Fortune/State Department alumna? If so, who was the alumna and what reasons did the alumna give for her recommendation?
5.Additional information you would like to include about the candidate (optional):
Date of Nomination:
Name and Signature of Nominating Officer:
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