CONTACT & WORK INFORMATION Note: mandatory fields …



CONTACT & WORK INFORMATION Note: mandatory fields marked by ** Name:Gender:* Email address:* Phone number:Employer:* Town in Which You’re Working:Current Job Title:* Town in Which You’re Living:Time in Current Job:* Travel for Work? (%) PERSONAL INFORMATION Anything else you would like to share about yourself? FORMTEXT ?????PROFESSIONAL INFORMATION Note: mandatory fields marked by ** PMI Membership #: FORMTEXT ?????* Are you a: FORMCHECKBOX CAPM FORMCHECKBOX PMP FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX N/A* Number of years as a Project Manager or working in Project Management: FORMTEXT ?????* Industry (e.g. Health Care): FORMTEXT ?????* Field (e.g. Information Technology): FORMTEXT ?????ROLE Note: mandatory fields marked by ** I am interested in being a: FORMCHECKBOX Mentor (PMP required) FORMCHECKBOX MenteeMENTEE – INDICATE ANY PREFERENCES FOR YOUR MENTORPrefer a mentor / mentee with the following characteristics:Gender FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX No preferenceIndustry FORMCHECKBOX Similar Industry FORMCHECKBOX Different Industry FORMCHECKBOX No preferenceSimilar Field FORMCHECKBOX Similar Field FORMCHECKBOX Different Field FORMCHECKBOX No preferenceSame Location FORMCHECKBOX Similar Work Location FORMCHECKBOX Similar Home Location FORMCHECKBOX No preferenceMentoring Schedule FORMCHECKBOX Weekdays / Weeknights FORMCHECKBOX Weekends FORMCHECKBOX No preferenceIf available, I would like the following individual to be my mentor (please write-in): FORMTEXT ?????Please list any specific industry, field, or other areas of interest you would like mentoring: FORMTEXT ?????Please list project management topics you would like to address during this program:MENTOR – INDICATE ANY PREFERENCES FOR YOUR MENTEEWould you prefer to mentor in a specific industry or field? If so, please list: FORMTEXT ?????ALL Note: mandatory fields marked by ** To complete the Mentoring Program, attendance at the three group meetings is required. Please confirm you can attend the following meetings in person:Kick-Off FORMCHECKBOX Saturday, September 28, 2019, 9:00am to 12:00pmHilton Garden Inn Burlington, 5 Wheeler Road, Burlington, MA 01803Mid-Point FORMCHECKBOX Saturday, January 11, 2020, 9:00am to 12:00pmMicrosoft Burlington, 5 Wayside Road, Burlington, MA 01803Wrap-Up FORMCHECKBOX Saturday, April 25, 2020, 9:00am to 12:00pmMicrosoft Burlington, 5 Wayside Road, Burlington, MA 01803List goals / desired outcomes from participation in the Mentoring Program: FORMTEXT ?????Are there any restrictions or additional information that would be helpful in processing your application? FORMTEXT ?????* How did you hear about the program? (e.g. chapter meeting): FORMTEXT ?????SIGNATURE Note: mandatory fields marked by ** Signature:* Date: Email Completed Form to: mentoring@ ................
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