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Mentoring Emerald Coast Mentor Application Form

Vision Statement:
Mentoring Emerald Coast is world class in connecting experience with potential.

The Mentoring Emerald Coast Program prides itself on being extremely beneficial to you whether you are engaged as a Mentor, a Mentee, or Sponsor.

Contact Seth Luttrell with any questions at 850.244.8191 or e-mail seth@fwbchamber.org.

Please Complete all Information Below:

First Name *

Last Name *

Title: *

Business Name: *

Type of Business: *

Address Line 1 *

Address Line 2

City *

Zip/Postal Code *

Business Phone: *

Cell Phone: *

E-Mail Address: *

Business Website:

Please list your community involvements, professional associations, and personal interests. *

Please list your three (3) greatest accomplishments (professional, social, or otherwise) achieved in the last 10 years. *

What has been the biggest accomplishment in your career? *

Please list your top three (3) strengths. *

Have you mentored previously in a structured mentoring environment? What was your experience in that program? *

What specific knowledge, skills, or experiences do you feel that you bring to the mentoring relationship? *

Why are you interested in being a mentor? What does a successful mentoring experience mean to you? *

What level/stage of business are you most interested in mentoring? *

Would you be interested in participating in group mentoring? *

The minimum commitment to the mentoring program requires your attendance at a training meeting, graduation banquet, and 10-12 meetings with your mentee. As a way to ensure the quality of this mentoring program, you will be expected to report the occurrence and scheduling of your meetings with your mentee. Please list how you will make this commitment. *

What specific goal(s) do you have for your mentoring process? Please list. *

Please indicate whether the following areas are a strength, an area you may need help with, or not applicable. This information will be one component considered in matching you with a business mentee. *

	Strength	Weakness	Not Applicable
Marketing & Advertising	Strength	Weakness	Not Applicable

Accounting/Finance	Strength	Weakness	Not Applicable

Talent Management	Strength	Weakness	Not Applicable

Business Planning	Strength	Weakness	Not Applicable

Inventory Management	Strength	Weakness	Not Applicable

Organizational Design	Strength	Weakness	Not Applicable

Customer Relations	Strength	Weakness	Not Applicable

Staff Relations	Strength	Weakness	Not Applicable

Operations & Production	Strength	Weakness	Not Applicable

Management/Leadership	Strength	Weakness	Not Applicable

Business Growth/Sales	Strength	Weakness	Not Applicable

Strategic Planning	Strength	Weakness	Not Applicable

Product Development	Strength	Weakness	Not Applicable

Quality Control	Strength	Weakness	Not Applicable

Peer Relations	Strength	Weakness	Not Applicable

Team Building	Strength	Weakness	Not Applicable

Please indicate all locations acceptable for meeting with your mentee: *

Fort Walton Beach Destin Niceville Santa Rosa Beach Freeport DeFuniak Springs All Locations Other Location (Not Listed)

I authorize the verification of all statements contained herein and the references listed above to give you any personal or otherwise and release all parties from all liability for any damage that may result from furnishing same to you. *

Yes No

Signature (please type your name): *

Date: *

Please upload your resume/bio and photo.

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