Full Name          
    Phone Work/Cell          
    E-Mail Addr        
    Job Title/Grade          
    Home Address  
                 

Please provide a brief career profile (summary of work experience, 
educational background, hobbies/special interest, etc).
                 

  Number of years at company    
  Number of years in current position    

List other professional work of fiels you've had exposure to: 
(e.g., you are currently a resources manager, but formerly an engineer)
                 

Describe the type of development expertise you can provide:
                 
 
I have a good understanding of career paths in the following fields:
                 

How many years of supervisory experience do you have? 
                 

I have technical expertise in the following area(s):
                 

I have been invokved in the following community outreach activities:
                 

What additional skills do you have to offer as a mentor? (Check any or all that apply)
An understanding of computing environment: culture, organizational knowledge 
Excellent communication skills 
Provide good sounding board to explore career options 
Understand the shortcuts for overcoming obstacles 
Can offer a different perspective 
Can share self motivation techniques 
Like to help others build confidence and take on new challenges

Have you ever had a mentor?
Yes 
No 

Have you ever been a mentor?
Yes 
No 

Why are you interested in being a mentor?
                 

Realistically, how much time can you invest in the mentoring partnership?
1 hour per week
2-3 hours per week
4 or more hours per week

Most available days/times:
                 

As a Mentor in the CS Mentorship program, I agree to make every effory to
communicate with my protege at least once per week. I also agree to make scheduled
meetings at any agreed upon times. I will report issues or porblems with my 
Mentor/Protefe relationship to program leaders or department representatives.

I have read the Mentoring Program announcement and understand the 
expectations and responsibilities of a Mentor in the Program, including 
communication requirement with my protege.

                 Yes 
                 No 

DISCLOSURE: Personal information provided on this form is given on a voluntary 
basis. Failure to provide this information will not result in ineligibility for the 
mentoring program, however it may result in an unsuccessful match.