Indiana Health Industry Forum Mentor Program: Mentor Registration Form

Mentor Registration Form

Name

First Name

Last Name

Title

Company Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Business Phone

Cell Phone

Email

Company Website

Is your company a member of IHIF?

Type of business (short description)

Company is

Manufacturer Distributor Consulting Other

If other please describe.

Please describe the role you have played in the development of your company/business.

Please describe your experience working with a Board of Directors/Advisory Board.

Number of years working in the health science industry.

Number of years retired from industry (if applicable).

Education

Ph.D. Masters B.A./B.Sc. MBA Law M.D.

Experience: Technical*

Yes No

Experience: Administrative

Yes No

Experience: International

Yes No

Why are you interested in becoming a mentor?

Please describe any previous mentorship experience.

How much time can you provide weekly as a mentor?

Any other skills you could offer

Please describe your greatest strength as a business leader.

Thank you for taking the time to fill out the mentor application. Please email a short bio to info@ihif.org.