Mentor/Host Application There is no deadline for mentor applications, you are welcome to apply year-round! Fields marked with a * are required Please Select One Host Mentor Both (Host and Mentor) NAME Last Name: * First Name: * HOME INFORMATION Mailing Address: * City: * State: * Zip/Postal Code * Cell Phone: * Home Phone: Email: * Social Media Facebook:(URL) Twitter:(Username) LinkedIn:(URL) Skype:(Username) PERSONAL/FAMILY INFORMATION Married? * Yes No If yes, Husband’s Name: Children? * Yes No If yes, Children’s ages: Hosting a student in your home can be stressful if the appropriate match is not made. Please tell us about yourself, your family, pets (if applicable), hobbies, etc. and if your family supportive of you participating in the program. * Are there any lifestyle or religion's incompatible with yours? * Please list all languages you fluently speak: * Would you be willing to complete a waiver that allows IEEW to use your name, business and image in their promotion of the program? * Yes No PROFESSIONAL INFORMATION (Please be detailed in completing your application so we can fully understand your business, get to know you and better match you with a student.) Name of your business: * Business Address: * Business Phone: * Business website: * Title: * Type of Industry: * How long have you owned your business? * How many employees do you have? * What percentage of the business do you own? * What is your annual business revenue? * Please describe your business in detail. The more detailed information you provide, the better match we can make. * Why are you interested in this mentorship program? * Mentorship of a PEACE THROUGH BUSINESS student is one of the most important pieces of her education and can be done via online, in-person or both. Therefore, we ask each mentor for a one year commitment, along with a commitment to provide IEEW with quarterly progress reports during that year. Are you willing to commit to the program for a year? * Yes No If your student is chosen for the Leadership Development program and travels to the U.S., would you be willing to continue your mentorship with your student? This requires the student living & working with you for one week during the U.S. portion of the Leadership Program. (See attached Mentorship Overview for a more complete explanation of mentor responsibilities). Please understand that this is a full-time + overtime commitment for this one week and may include daily transportation to and from any special events. * Yes No If your student is chosen for the Leadership Development program, and if you live outside the Dallas-Ft. Worth or Oklahoma City area, are you willing to provide roundtrip domestic airfare for your student to travel to your location and back? * Yes No How did you hear about the PEACE THROUGH BUSINESS ® Program? * By typing “yes’ below, if selected for the PEACE THROUGH BUSINESS ® Program, I hereby consent to the participation in and publication of interviews, the recording of interviews, photographs, movies or video tapes. I also grant the Institute for Economic Empowerment of Women (IEEW) the right to publish and distribute such materials for publicity purposes in any media format which include but are not limited to newspapers, magazines, television, radio, film, texting or any type of media on the Internet. I also grant IEEW the right to edit such materials, so long as the meaning of statements and interviews are not changed. If you agree with the above statement, please write/type “yes” in the following box * Please write yes in any of the following that apply to you. I am applying to be both a mentor and host. If so, please write yes in the following box I am applying to be an online mentor only. If so, please write yes in the following box Some mentors prefer to work in teams. Do list any team members: I am applying to be a host only. If so, please write yes in the following box. If you choose to serve only as a Host, then the Professional Information section is not required. I have read and understand the mentor/host description, and understand that the entire Mentor Manual will be available prior to the PTB program for my review. If you agree, please write “yes” in the following box Please provide the names, addresses, phone number, and email of 3 references below: 1. * 2. * 3. * 4 + 7 = *
