Your Name (required) Your Organisation Role(s) – indicate primary role: How long in your primary role? Office Location Your Email (required) Level of Role (Pick closest) Senior ManagerExecutiveCEODirectorBoard Chair Please provide a bio: What do you hope to achieve by participating in the mentoring program? (max 300 words): What would you like learn and develop most specifically through mentoring? Better understanding of strategic directionDevelopment of Leadership Skills such as ... (clarify below)Development of other professional skills such as ... (clarify below)Learn from others experience in areas including... (clarify below)Career planning and development adviceDeveloping work life balancing strategiesInfluencing skillsBecome a confident mentor myselfImproving self awareness and self confidenceIncreasing contacts and networkingAnything else? Expand on above if required... What training and development have you taken part in over the last few years? Please include any previous experience of mentoring you may have had to date (when, areas of focus, your role, etc). (max 300 words) How do you best learn? (eg brain storming strategies together, active learning – activities in life you can then reflect on, experiential, reading, talking, using pictures/flow charts, role plays, reflection) (max 200 words) Do you have any preferences or requirements you would like the Mentoring Committee to take in to account? This may include preferences for specific people or characteristics – positive or negative. This information is confidential and only used to assist the matching process. (150 words) Success of this program requires you to commit to attending a monthly meeting with your mentor (duration 1 – 1.5 hours)? Is there any reason why you may be unable to meet this commitment? What have you done to “pay it forward” and support and help others develop themselves, their career? (max 300 words) Have your subscribed to Verity leadership ($99 for 2019 program)? (Note: subscription is required to progress application for mentoring scholarship noting it is not a guarantee of receiving a scholarship. See our website for details on benefits of subscription) YesNo Anything else you would like us to know about you? Any concerns?