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Please complete the following application to apply as a mentor for the 2016 STL-ODN Mentoring
Program. Please send the completed application, along with a copy of your current resume to Karen Grace
( kgrace@peabodyenergy.com
).
C ONTACT I NFORMATION
Name:
Mailing Address:
City:
Telephone:
State: Zip Code:
Email Address:
P REFERRED M EETING L OCATION & A VAILABILITY
Where are you willing to meet? Preferred Meeting Time
Highlight all that apply.
Please rank from Most Preferred (5) to Least Preferred (1)
St. Louis City
St. Charles County
North County
South County
West County
Metro East – Edwardsville
Metro East – Fairview Heights
____ Before Work/Breakfast
____ Morning
____ Mid-Day/Lunch
____Afternoon
____After Work
____Weekend
Other:
E XTENDED R ESPONSE Q UESTION
Please respond on a separate form and attach to application. You may respond in paragraph or bullet form.
1.
What are your short-term (1-2 year) and long-term (3-5 year) career goals? How will a mentor facilitate this development?
2.
What do you hope to gain from participating in the program?
3.
Please describe any training or development in which you have participated to support your career trajectory.
4.
Are you able to attend the Kick-off Meeting on January 26, 2016?
5.
Are you willing to commit at least two hours a month to your mentoring relationship?
6.
Based on needs and fit, would you be willing to participate in a mentoring triad (one mentor, two mentees)?

A REAS OF I NTEREST
(Highlight all that apply.)
Large Systems Change Interventions
Culture Change
Organizational Transformation
Organizational Learning and Knowledge Management
Change Management
Mergers and Acquisitions
Workforce Diversity
Organization Effectiveness Interventions
Strategic Thinking/Planning
Employee Development
Organizational Assessment
Engagement and Culture Surveys
Organization Design
Work Redesign
Downsizing/Restructuring
Talent Review/Succession Planning
Performance Management
Interpersonal & Intergroup Interventions
Team Building/Team Learning
Conflict Management
Process Consultation
Action Learning
Mentoring
Coaching
Individual Effectiveness Interventions
Executive Coaching
Career Planning and Development
Individual Assessment
Other Areas of Interest
Other

Y OUR E XPERIENCE
In order to appropriately match mentors with mentees, it is necessary for the committee to have an understanding of your OD experience. You can provide us with this information by attaching a resume or completing the following section.
E DUCATION
Degrees:
Certifications:
I am a … (please select one:)
A student
Employed Full-time
Employed Part-time
Seeking employment
C URRENT P OSITION (I F E MPLOYED )
Current Title:
Current Organization:
Industry:
# of Employees:
Years in OD Field:
Years in Current Position:
Thank you for your interest in the St. Louis Organization Development Mentoring Program!
Please email completed applications along with a copy of your current resume or curriculum vitae to
Karen Grace ( kgrace@peabodyenergy.com
) by J ANUARY 10, 2016.
Please note:

Acceptance into the program will be based on the requirements outlined as well as the availability of an appropriate match.

Participants will be selected and matched by January 19, 2016.

Program Kick-off to be held January 26.
