Mentor Form

Mentor Name and Title:*

Mentor Phone:*

Mentor Email:*

Please describe briefly your areas of expertise:

Expertise with specific type of collections:

Did you serve as a mentor in the VMGA "Mentors in Vermont" program?

Yes

Please describe briefly your background (experience, education, training):

I understand that service in the Collections Care Mentoring Program is voluntary; mentors may receive reimbursement for expenses :*

Yes

I have read, understood and will comply with the program guidelines (please see link at top of page):*

Yes

I will make every effort to assist the applicant organization in scheduling the site visit:*

Yes

Contact Information

Company:

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country / Location:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Email:*

Thank you!

Vermont Historical Society • 60 Washington Street • Barre, Vermont 05641 • (802) 479-8500
www.vermonthistory.org