Expression of Interest Form Mentoring within LDW Leadership Development for Women Program


Leadership Development for Women Program

Expression of Interest Form

Mentoring within LDW

The personal information you provide on this form is protected by the Privacy and Personal Information Protection Act 1998

(NSW).Provision of this information is a requirement of participation in CSU's Leadership Development for Women Program.

Access to the information you provide is available to yourself, your supervisor and Director/Executive Director or Dean, the course providers and those persons authorised to access the information in the course of their duties at Charles Sturt

University.This document will be stored at The Division of Human Resources, CSU, Wagga Wagga

Mentor Details

Title (e.g. Dr, Ms, etc): Family Name: Given Name:

Section or School: CSU Campus or Site:

Position Title:

Contact Telephone Number:

Academic / General Staff:

Email Address:

Level of Appointment:

Part-Time / Full-Time Status (if Part-Time, please indicate FTE e.g. 0.5):

Part-Time Number of hours: _________________


Signature: Date:


Expressions of Interest for Mentoring for LDW Program

Please provide a few points outlining your interest in the program and how you may contribute as a mentor?

Please send form to