Mentor Request Form

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MENTOR REQUEST FORM

PERSONAL INFORMATION

First Name

Last Name

Contact Telephone Number/s:


(With Country and City Code)

Contact e-mail Address

Based in (city)
Educational background (degree,
university)

Year of graduation

Current Occupation

MORE INFORMATION ABOUT YOUR VENTURE

Briefly describe your


business idea /opportunity
(not over 250 Words)
What is your industry type? • Technology Sector
(e.g. IT/BPO/Retail/Hospitality
• Education
• Alternate energy/ Cleantech
• Healthcare
• Consumer goods and services
• Financial services
• Retail
• Social
What consumer pain point is
your product/service
addressing?
Name of the company and
Year it was founded
How big is the Entrepreneur
Team ?
Type of Company • Idea Stage
• Pre Revenue
• Growth Stage

Revised on May 12, 2010


EXPECTATIONS: Please share your expectations with us to enable us to help you in the best
possible manner

What are your expectations


from the Mentor during this
program?

Please describe in about 200


words any specific issue that
you are seeking guidance or
would like to be mentored
on.

Have you requested and/or


received Mentoring before

Revised on May 12, 2010

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