Request a Mentor

The information that you provide will be kept confidential and will only be used to pair you with a Mentor who best matches your needs.

Request a Mentor
Name:
Member No:
Position/Title:
Company:
Contact Information:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Phone:
Email:
Business Type:
Consulting Government Laboratory
Construction Health Care Manufacturing
Education Insurance Service
Other        
If you chose "other" business type...
Please Specify:
Education:
Previous Work Experience (Companies & Positions):
What do you hope to achieve from the mentoring program?
Do you have any Professional Certifications?
CSP CIH CHMM
PE Other    
If you chose "other" Professional Certification(s):
Please Specify:
Please indicate three of the developmental needs below that are most important to you to focus on during the mentoring program.
Network Development Negotiating Politics/Culture Career Planning
Influence Management Financial Acumen Other
Strategic Thinking/Planning Career/Family Balance    
If you chose "other" developmental need....
Please Specify:
Is there anything else that you think would be helpful for us to consider when evaluating your application?
Thank you for your interest in the Mentoring Program! We have added a simple tool to prevent spam attacks on our signup page. Please think back to the higher math that you learned in grade school and complete the math challenge before proceeding. Add the two numbers that appear and type your answer in the box provided.
MathGuard security question, please solve:

34R         TRK      
K B    B      Y   DMH
IUE   PWR     K      
Q J    H      4   S89
QDG           L

Chapter Contacts

For more information about the ASSE Northwest Chapter, please contact:

Chapter President
William R. "Bill" Stuart
Phone: 612-671-8431

Website Editor
Richard "Rick" Johnson
Phone: 763-551-1022