ELP Mentor Application Form

							                                             Emerging Leaders Program
                                              Mentor Application Form
The Emerging Leaders Program (ELP) is seeking qualified Mentors (GS -13 and above) to provide guidance, professional
exposure and an understanding of the Department’s goals and expectations to ELP interns in support of their leadership
development. Please review roles and responsibilities of an ELP Mentor before completing the application.

The information you provide on this form will assist us in making an appropriate match between you and the ELP intern. Please
fill-in all spaces as accurately and completely as you can. When you have finished, email the application to the HHS Mentoring
Program Manager at Terri.Hillard-Gibson@psc.gov.

                                      Please complete by: December 14, 2007

Name:                                                            Rank/ Grade:

Job Title:                                                       Operating Division (OPDIV):

City:                                                            Email:

State:
Work Phone (_ _ _)                                               Years in the Federal Government:

                                              Experiences
Previous Mentoring Experience                 ____ Yes                ____ No
Brief description of your career and the duties you perform in your current position.: (No more than 100 words)




I agree to serve as a mentor in the Emerging Leader Program for 18 months. I understand that I
must complete mentor training, a mentee/mentor agreement and evaluation progress reports. This
application will be shared with the appointed Mentoring Program Coordinator, ELP Program Staff,
and ELP intern .

Mentee’s Name:

Please submit the application via email to HHS Mentoring Program Manager,
Terri.Hillard-Gibson@psc.gov.