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Mentoring Application Form

[Download editable version of this form.]

Name: Today’s Date: 
Title: Agency: 
Office Mailing Address: 
Office Phone Number: Office Email Address: 
Current Occupational Series: 
Current Series/Grade: Length of Government Service: 
I Am a Supervisor/Manager (Y/N): 

 

Background Information:

1. Why Do You Want To Be A Mentor? (1000 Characters Max):

 

2. Please rate your proficiency in each Competency below using these categories:

4 – Highly Proficient3 – Working Knowledge
2 – Room for Improvement1 – Limited Knowledge

Fundamental Competencies

1. Interpersonal Skills4321
2. Written Communication4321
3. Oral Communication4321
4. Integrity/Honesty4321
5. Public Service Motivation4321

Leading Change

1. Creativity And Innovation4321
2. External Awareness4321
3. Flexibility Resilience4321
4. Strategic Thinking4321

Leading People

1. Conflict Management4321
2. Leveraging Diversity4321
3. Developing Others4321
4. Team Building4321

Results Driven

1. Accountability4321
2. Customer Service4321
3. Decisiveness4321
4. Entrepreneurship4321
5. Problem Solving4321
6. Technical Credibility4321

Business Acumen

1. Financial Management4321
2. Human Capital Management4321
3. Technology Management4321

Building Coalitions

1. Partnering4321
2. Political Savvy4321
3. Influencing And Negotiating4321

 

3. What Do You Think A Mentee Can Learn From You? (600 Characters Max):

 

4. What Are Your Interests Or Hobbies Outside Of Work? (600 Characters Max):

 

 

 

Mentor Signature: ____________________________________________________

Supervisor Signature: ____________________________________________________

By signing the application you acknowledge the employee above can participate in the Mentor Program.

 

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