PERSONAL INFORMATION

Title

Last Name*

First Name*

Home Address*

City

State*

Zip*

Home Phone*

Cellular Phone*

Email*

Married*
YesNo

Spouse's Name

Children*
YesNo

If yes, how many and what ages?

Bringing someone into your home can be a stressful time if an appropriate match is not made. Please provide us with some information about you, your family, your pets, your hobbies, etc., and how your family feels about participating in this program.*

Are there any lifestyles or religions incompatible with yours?*

PROFESSIONAL INFORMATION

Business Name*

Business Address*

City*

State*

Zip*

Business Phone*

Please describe your business in detail. The more information we have, the better match we can make.*

How long have you had your business?*

How many employees do you have?*

What percentage of the business do you own?*

Annual Revenues*
Under $50,000$50,000 - $100,000$100,000 - $500,000$500,000 - $1,000,000Over $1,000,000

Please list all languages you speak and degree of fluency.*

If you live outside of Dallas, Texas, are you willing to provide the roundtrip airfare for your mentee to travel to your location and back to Dallas?* (Please answer yes or no, but this payment ability is not a requirement.)
YesNo

Why are you interested in this mentorship program?*

How did you hear about the PEACE THROUGH BUSINESS program?*

Please attach your photo for our conference book. (File types must be jpg, gif or PDF)*

Please attach your bio for our conference book. (File types must be doc or docx)*

By checking "yes" below, if selected for the PEACE THROUGH BUSINESS program, I hereby consent to the participation in and publication of interviews, the recording of interviews, photographs, movies or video tapes. I also grant the Institute for Economic Empowerment of Women (IEEW) the right to publish and distribute such materials for publicity purposes in any media format. Media formats include, but are not limited to, newspapers, magazines, television, radio, film, texting or any type of media on the Internet. I also grant IEEW the right to edit such materials, so long as the meaning of statements and interview are not changed. I also understand that I must gain IEEW's permission before using the PEACE THROUGH BUSINESS or IEEW mark in any press releases or any other media and marketing materials.*
YesNo

I have read and understand the Mentor overview and responsibilities.*
YesNo

Once you successfully submit your application by pressing the button below, you will receive a confirmation e-mail.