Mentor Match Program:

MENTOR APPLICATION

Thank you for your interest in being a Mentor for out Mentor Match Program! Please complete this application to help us get to know you and your business, as well as how to contact you.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Race

Caucasian

African American/Black

Hispanic/Latino

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaskan

Other

Business Name

Date Established

YYYY

Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Website

http://

Briefly describe your business

Briefly describe your areas of expertise

How long have you been in business?

Business Legal Structure

Industry

If other, please specify

Number of employees (FT, PT)

Have you ever had your own mentor? Describe the experience.

Have you ever been a mentor before? Describe the experience.

What kind of business do you feel you could help best?

Terms for the program: Sign and date in box below

I understand that by completing this application, I am agreeing to the terms of the Mentor Match program facilitated by the Women’s Small Business Accelerator, Inc. I also understand that the WSBA does not perform any tasks on behalf of or for program attendees. As a volunteer and program attendee you take responsibility for completing the program to the best of your ability and give only the advice and feedback that you believe will benefit your Mentee. You further understand that the Mentee agrees to take full responsibility and assumes all liability for the implementation of any advice or feedback given by you. Completion and submission of the application is merely a request for entrance into the Mentor Match program, and not a guarantee of acceptance, as participation in the program is based on availability of a Mentee to match a specific Mentor’s based on the Mentee’s needs. Information provided in this form helps the WSBA understand the audience we address and will be kept strictly confidential within WSBA and its partner organizations and evaluators. Additional terms: • All participants, including Mentors and Mentees, and all volunteers will be required to sign a non- disclosure/confidentiality agreement. • All participants, including Mentors and Mentees, and volunteers will be required to give the WSBA permission to use their name, company name and a professional photo in any WSBA media release, marketing material, and on the WSBA website for the purpose of promoting WSBA and its programs. However, no proprietary information will be used. By completing this application, you are giving the WSBA permission to use the information described above. • Mentors are required to complete an orientation program before being matched with a Mentee. This program will cover the expectations of being a Mentor, how to work with Mentees, and working with the WSBA. I understand that typing my name in the box below is my electronic signature, agreeing to the terms stated above.