**U.S. Department of Transportation**

**Leaders for Tomorrow Mentoring Program**

**Protégé Profile (GS-13s and 14s)**

The information you provide on this form will assist us in making an
appropriate match between you and potential mentors. Please be as
specific as possible. This form must be submitted to your organization's
training manager/coordinator and to the OST Program Manager. For further
information, please contact OST/M-17 Mentoring Program Manager, Patrice
Blackman, on (202) 366-9844. Thank you for your interest in the program.

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  Name:                                   Job Title/Series/Grade:      

  Organization:                           E-mail Address:     

  Street Address:\_                       Phone Number:     

  City, State, Zip:                       Fax Number:     
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Summary of Current Position/Other Professional Experiences (attach add'l
documents as needed):

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What are your expectations for this program?

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Please identify skills/competencies/knowledge you are most interested in
developing/enhancing:

Interpersonal Skills Goal Setting Skills Communication Skills Management
Skills

Conflict Resolution Time Management Networking Skills Leadership Skills

Counseling/Coaching Skills

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| Technical Skills (please specify)                                     |
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|                                                                       |
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| Other (please specify)                                                |
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| Please describe any additional strengths or skills, as well as goals  |
| for further development:                                              |
|                                                                       |
|                                                                       |
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What are your career goals?

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  Describe your educational background:     

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  Identify a few hobbies and non-work related interests:      

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Signature:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:3/27/2003