Mentee Application

Step 1 of 4

What region are you applying for?(Required)

HHS Region 5 Great Lakes ATTC (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin)

HHS Region 6 South Southwest ATTC (Arkansas, Louisiana, Oklahoma, Texas, New Mexico)

HHS Region 8 Mountain Plains ATTC (Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming)

Name(Required)

First Last

Credentials(Required)

Agency/Organization(Required)

Current Role/Position(Required)

How would you describe the community in which you work:(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Mobile Phone Number(Required)

Email Address(Required)

Upload a CV or Resume(Required)

Accepted file types: pdf, Max. file size: 5 MB.

Do you currently supervise other staff?(Required)

Yes

How many individuals do you supervise?(Required)

How many years have you supervised other staff members?(Required)

Name of person that referred you to the Leadership Academy(Required)