1.	Department

2.	Name

3.	Date

4.	As a prospective mentee, I would be interested in mentoring in the following areas: (Check all that apply)
	receiving basic knowledge of what it means to be a faculty administrator    learning about the organizational structure, priorities, politics, culture    receiving guidance on advancement in administrative positions in the university    participating in an administrative project    in a specific area    in a general area

5.	Specify specific area if checked above.