MDG Mentee Application Form
RequiredRequired Question(s)
Required 1.
Please enter the information indicated below.

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com

Required 2.

Name of Employer (including self-employed or in transition).

 

50 characters left.
Required 3.

 

In what city or town do you work?


 

50 characters left.
Required 4.
In what city or town do you live?
 

50 characters left.
Required 5.

 

Please copy/paste the link to your LinkedIn profile here. This information will help us with our match-making decisions.


 

350 characters left.
Required 6.

 

Have you been a mentee in another organization's mentoring program before?


Yes
No
7.
If you answered YES to the question above - I was involved as a:
Mentor
Mentee
Both
Required 8.

 

In order to continue, please confirm that if you are matched, you will be able to commit to the program for the next 6 months. Having the time for this program is the key to success.

This commitment means that you will make every effort to meet with your match at least one time per month either in person, by phone or by Skype. In addition, you will be expected to attend the kick off meeting in late January, 2016 and are encouraged to attend another in-person event throughout the program.


YES, I expect that I can make this commitment and would like to continue the application
NO, I can't make this commitment and would not like to continue the application.
[If you answered NO, to exit simply close the window] 
 
For the next question(s), please be as specific as you can be in describing what you hope to gain from the Program. Your answer here, along with your Linkedin profile, will play a significant role in the match-making decisions made by the committee.
 
Required 9.

In your own words, why do you want to participate in the Peer Mentor Program as a Mentee?

 

350 characters left.
Which of the following best describes what you hope to gain from the Program as a Mentee? 

Please answer no more than THREE of Questions 10-14 (you may select as many boxes as you wish within the three questions that you select).
 
10.

Grow Business

I want to understand how to start a new business
I want to explore how to hire new employees
I want to learn how to work in a management role
I want advice on how to grow my business
11.

 Skill Development

I want to better understand my skillset and how best to leverage it
I want to learn how to work better independently
12.

Changing Paths

I want to explore alternate career paths
I want to understand how to work within my new company and/or new position
13.

Interpersonal

I want to learn how to work better within a team
I want to learn how to change the way I am perceived
I want advice on how to network in the medical device/life science/healthcare industry and /or the business community
I want advice on how to work better with my clientele
I want to learn how to deal with a difficult workplace situation
I want to learn how to standout or excel in my workplace
14.

General Goals

I want to take risks or make difficult/important decisions
I want to set clear goals to work towards achieving and overcoming obstacles
Other
15.

If you selected OTHER in the question above, please specify.

 

350 characters left.
Required 16.

 

Which of the following best describes what you hope to gain from the Program in general? Please select all that apply.


I want to gain new perspectives and fresh insights
I want someone who I can talk to about both my professional and personal life
I want to learn new things about myself
I want to develop a new and/or lasting relationship
I want to learn how to be a mentor or enhance my mentoring skill
Required 17.

 

Please check the industries that would be a good match for you in a mentor. 

Please limit your choices to TWO industries that are the BEST fit for you. This is not a guarantee that you will be matched to someone in this industry, but every effort is made to make a good match.


Medical device (start up / small)
Medical device (medium)
Medical device (large)
Healthcare
Pharmaceutical
Combination product
Biotech
Consulting
Other
18.

If you selected OTHER in the question above, please specify.

 

350 characters left.
Required 19.

 

In which area(s) do you most need help? 
Please select no more than THREE items. 


Entrepreneurship
Executive Issues
Career Change
Work/Life Juggling
Organizational Dynamics
Career Advancement
Outsourcing
Business Process Improvement
International Business Experience
Other
20.

If you selected OTHER in the question above, please specify.

 

350 characters left.
Required 21.

How would you most like to meet with your mentor? (Select all that apply)

In person
By phone
By email
By Skype
No preference
Required 22.

 

What is the most important consideration for you in your match? 

Please choose ONE.


Geography
Expertise
Experience level/professional level of contact requested/available
Other
Required 23.

A) If you selected OTHER in the question above, please specify.

B) For any of the considerations selected above, please explain your choice.

 

350 characters left.
Thank you for your interesting in participating in the MDG mentoring program (pilot).