The Chair Academy : Mentor Selection Form

The Chair Academy - Worldwide Leadership Training for Post Secondary Leaders

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Mentor Selection Form

Please fill in the information below. If you have questions concerning the form, please contact the Academy Liaison. After submitting this form, please press the "back" button on your browser toolbar to return to your class web page.

Participant Information

Your Name:

Your College (please spell out the name):

Internal Institutional Mentor

(please enter the information of the mentor you have chosen):

Name:	Email:
Title:	College:
College Address:	City, State, Zip:
Country:	Province (if applicable):
Phone #:	Fax #:

External Mentor

(please enter the information of your second mentor):

Name:	Email:
Title:	College:
College Address:	City, State, Zip:
Country:	Province (if applicable):
Phone #:	Fax #:

Untitled Document

The Chair Academy's
2012 International Leadership Conference
March 26-29, 2012
Atlanta, Georgia

Hosted by
Georgia Perimeter College

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