Full Name:                                           Email Address:
                   

Position:                                             Certified Since:      
                   

Credentials:                                         Recertification End Date:
                    

Number of times you took certification             Years of Experience in HR  
exam before passing successfully:                      0-4 5-9 10-14 15+
                        

Why did you decide to become HR certified?     
   

Why are you interested in becoming a mentor?
Include what you expect to gain from being involved.

     
Past mentor experience
(whether you were the mentor or mentee):


How much time per week can you commit?
2-5 6-10 11-15 16+