PROFESSIONAL MENTORING PROGRAM
Lake Champlain Regional Chamber of Commerce
60 Main Street, Suite 100
Burlington, VT 05401
Please complete and return by email to
DEADLINE FOR APPLICATIONS: Tuesday, August 1st 2017
PROFESSIONAL MENTORING PROGRAM APPLICATION
Last Name: , First Name: , Middle Initial:
Preferred Name:
Home Address (Street, City, Zip):
Employer: Date Employment Began:
Current Position:
Business Address (Street, City, Zip)
Phone: Email:
Brief Description of Duties:
Is the business a current member of the Lake Champlain Regional Chamber of Commerce?
Yes: _____ No: _____
A. Education and Specialized Training Programs (or attach resume)
Name and City of School/Program / Dates Attended / Degree/Major(Where Applicable)
B. Employment History (or attach resume)
If you have been with your present employer for less than three years, please list previous employment in the last ten years.
C. Organizations and Activities (or attach resume)
Please list, in order of importance to you, community, civic, professional, business, religious, social, athletic, and other organizations with which you have been involved in the last five years.
D. Please answer the following questions.
1) Please review the list of participating mentors and list the three mentors you are most interested in being paired with below. Your selections will be used during the application process. We do not guarantee that you will be assigned a particular mentor if accepted into the program. Mentors and mentees will be paired based on interests and opportunities for a successful professional development relationship.
1)
2)
3)
2) What do you hope to gain from a professional mentoring relationship?
3) Where do you see yourself professionally in 5 years? 10 years?
E. References
Please list two references below:
Name/Title:
Business Title:
Phone:
Name/Title:
Business Title:
Phone:
F. Tuition/Responsibilities
Tuition is due upon acceptance and must be received prior to the start of the Program. Tuition is $50 for members and $100 for non-members. Please mail a check or contact the Chamber at 802-863-3489 to pay by credit. No refunds will be issued.
All applications are subject to confidential evaluation and applicants 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.
Applicant Signature: Date: