Mentee Application
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Emerging Leaders

ASPAN Mentee Application

Personal Information

Your First and Last Name

Your Email

Home Address

City, State, Zip

Work Affiliation

Home or Cell Phone

Work Phone

Fax Number

Highest Education

ASPAN Member #



Describe your interests in the following:

I would like to be a committee and/or strategic work team (SWT) member.

If Yes, which committee(s) and/or SWT(s)?

Are you interested in committees and/or SWTs on the national or component level?

I would like to be a committee chair and/or SWT coordinator.

If Yes, which committee and/or SWT would you have an interest in leading?

Are you interested in being a chair and/or coordinator on the national or component level?

I would like to become a national officer.

If yes, which national board position?

I would like to become a component officer.

If Yes, which component board position?

Other interests - please explain:

Experience and Expectations

Professional experiences:

Professional organizational experiences:

Describe your career goals and your timeframe as to when you will achieve these plans.

Long term:

Short term:

What are your expectations of this program?

What specific characteristics or experiences are you looking for in a mentor?

Do you have a specific mentor request? If so, please list 1-2 names.

Additional comments:

All fields with a * must be filled in. If you do not see a confirmation screen after hitting send, please go back and make sure all * fields are completed.

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