Mentor Application 1. Name* First Last 2. Company Name 3. Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 4. Email* 5. Phone6. Job Title 7. Which sector of the water/environment industry do you work? 8. Why do you wish to participate in the NEWEA Mentoring Program?9. What do you hope to gain from participating in the NEWEA Mentoring Program?10. Briefly state previous experience you may have had as a mentor. If this is not applicable, skip to the next question.11. Are you associated with any other industry professional organizations aside from NEWEA? If so, please list12. Are you a member of NEWEA?* Yes No 13. Will you be able to fulfill the program requirement of meeting once quarterly (every three months) with your mentee in person or over the phone?* Yes No I'm not sure 14. Please indicate how many years of water/wastewater industry experience you have.* 0-14 years 15-25 years More than 25 years If not, how often will you be able to commit to meeting your mentee? 15. Please provide a brief biography of yourself (no more than 5-6 sentences) so we can more accurately place you with a suitable mentee. Δ