NSW PRIA MENTORING PROGRAMME
APPLICATION FORM
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PERSONAL DETAILS
Name: _________________________________________________
Age:
 18-21
 22-29
 30-39
 40 +
Company: _______________________________________________
Address: _________________________________________________________________________
__________________________________________________________________________________
Phone: _____________________________
Fax: ______________________________
Email: __________________________________
Mobile: ____________________________
Years of experience in public relations or a related field: __________
I wish to be a:  Mentee
 Mentor
I have/have not previously been involved in a Mentor/Mentee relationship within the PRIA or
another organisation.
If you have been involved in a Mentor/Mentee relationship, briefly describe with whom and when:
__________________________________________________________________________________
__________________________________________________________________________________
WORK HISTORY
Current position held:
____________________________________________________________________
Reporting to:
____________________________________________________________________
Responsibilities:
__________________________________________________________________________________
__________________________________________________________________________________
Brief list of previous employers, position and responsibilities:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
GENERAL
1) Mentors and Mentees: Tell us why you want to be part of the Programme (please tick as many as
appropriate):
Mentee
Mentor
 Career move/ development outside of current area
 Career development in current area
 Career guidance
 Skill development
 Someone to confide in
 Career development
 Opportunity to ‘give back’ to the industry
 Mentoring experience
 Help someone unlock their potential
 Other ____________________________
2) Mentee: Is there a specific industry you would seek your Mentor to be associated with or type of
role/background, you would wish your Mentor to have experience in?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
3) Mentors and Mentees: For how long do you wish to take part in this Programme:
 Three months
 Six months
 As long as the relationship requires
4) Are there any specific times or days that best suit you to meet with your Mentee/Mentor?
__________________________________________________________________________________
5) How would you like to be contacted by your Mentor/Mentee?
 Phone
 Email
 SMS
6) Mentees: What specific skills/experience are you looking for in your mentor?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Mentors: What specific skills/experience can you offer?
 Business PR
 Career move in-house to consultancy or
vice versa
 Community relations
 Consultancy experience
 Consumer PR
 Events organisation
 Government relations
SIGNATURE: ___________________________
 Guidance for tough economic times
 In-house experience
 Internal communications
 Longer-term career planning/management
 Media relations
 Starting your own PR consultancy
other________________________________
DATE: ________________________
Please return this form to PRIA NSW by the following methods:
Email: nsw@pria.com.au | Fax: 02 9331 3559| Post: PRIA NSW Mentoring Program, Suite 33, 94
Oxford St. Darlinghurst NSW 2010