CIPD South Yorkshire & District
Mentoring Scheme
Mentor Application Form
Section A - Personal Information
Name (first, middle, last)
Phone (home/mobile)
Email
CIPD Membership –
Number & Grade
Please introduce yourself
and your career to date
(max 150 words)
What are your main areas
of HR knowledge, skills
and experience?
Have you had previous
experience of Mentoring? If
yes, please provide brief
details
Have you had any formal
training? If yes, please
provide brief details and
qualifications
Where are you prepared to
travel to meet your
Mentee? (Towns/area)
Personal interests
Section B - Personal Profile
Current employer
Sector/Industry
Location
Job title
What time of day will you
be available for meetings?
What are the main reasons
for wanting to become a
Mentor?
What do you think you can
bring to a Mentoring
relationship?
By signing this form:
1
October 2015
I declare that the information above is correct at the time of completion.
I understand that the role of Mentor is voluntary and that no expenses can be claimed.
I will participate in Mentoring Scheme activities wherever possible, in order share
experiences, participate in peer mentoring and learn about new initiatives/changes to
processes.
Signed________________________________ Date__________________________
Please use electronic signature if available
Please expand this form to enter your details. Once completed, please return to our
Mentoring Scheme Coordinator Kathy Town, via the Mentoring Scheme page on the
website.
Information supplied on this form will only be used for the purpose of administering
our Mentoring Scheme. However, the information provided at Section A will be used
to create a Mentor Profile for you, which will be uploaded onto the South Yorkshire &
District CIPD website, Mentoring Scheme page.
2
October 2015