mentorship form

Full Name

Email Address

Location (City/Country)

LinkedIn Profile URL (Optional, but highly recommended)

Current Role & Company (if any)

Years of Work Experience
[radio* work-experience use_label_element
"0–1 years"
"2–5 years"
"6–10 years"
"10+ years"]

Industry / Career Field

What are your short-term (1–2 years) and long-term (5–10 years) career goals?

What specific areas would you like mentorship in? (Check all that apply)

Career transitionsLeadership developmentStrategic career planningBreaking into top companies (e.g., Microsoft, Oracle, etc.)

Others (please specify)

Why do you want to be mentored by me?

What drew you to this program and what do you hope to gain?

How committed are you to this mentorship program?
[radio* commitment-level use_label_element
"Very committed – I’m ready to put in the work"
"Moderately committed – I’m exploring options"
"Just curious – I want to learn more before committing"]

Any additional information you'd like to share?