ASIS Boston - Protégé Application Assessment Form

* First Name

* Last Name

* Email

* Have you ever been in a Protégé/Mentor relationship/program?

No
Yes, but it was an informal relationship
Yes, but it was in a formal program

* If you have been in a Protégé/Mentor relationship/program in the past, what did you find valuable? What wasn’t valuable about the relationship/program?

* What are your career objectives?

* What is your area of expertise/field of employment? Please list all experience or job description.

* What do you plan to achieve as a result of this program? Please include professional, academic, personal, leadership, extracurricular, and any other goals you plan to accomplish via this program.

* Do you want to be matched with someone in your area of expertise?

Yes, I would like to be matched with a Mentor from my field of my security
No, I would like to be matched with someone from a different field of security.

* Would you like to be assigned to a mentor specifically for certification purposes?

Yes
No

* What do you see as the purpose of your mentored experience? Select your three most important mentoring needs at this time.

Other

* What mechanisms of communication do you have available to you to interact with your Protégé? Supply information on those you wish to use.

Business Phone
Cell Phone
Business e-mail
Personal e-mail
Go-to-meeting capabilities
Live chat
Video conferencing
Face-to-face meetings

Other

* What type of feedback do you expect from your Mentor?

* Do you want your manager to participate in the program with you?

Yes, I would like feedback to my manager from my Mentor on my progress.
No, I do not want my manager to participate in the program with me. I will share my progress as I feel necessary.

* How long do you feel participation in this program will take to achieve your stated goal?

6 months or less-i.e., specific project
1 year or less-i.e., general plan
Longer than 1 year-continuing enhancement

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