**Pennsylvania NRCS Mentoring Program**

**Protégé Application**

Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Position\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Office\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
City\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Ext.
\_\_\_\_\_\_\_\_\_\_\_
Fax\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E-mail
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Educational Background*: Highest Degree: \_\_\_\_\_High School
\_\_\_\_\_Associate

\_\_\_\_\_Bachelor's \_\_\_\_\_Master's

College Major:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Further education or classes that have extended your professional growth
and development during the past 5-10 years:

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For the mentoring program to work effectively, we need to know more
about you. This will allow your mentor to identify needs and determine
the initial area(s) of focus.

*Work Experience* Years with NRCS\_\_\_\_\_\_ Years in Current
Position\_\_\_\_\_\_

Previous work and/or college experience

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Specific areas of
expertise\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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What are your long/short term goals?
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What would you like to accomplish as a result of this program?
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Additional
Comments\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Signature Date

***All information will be kept confidential and will only be shared
with your mentor.***

***Thank you!***

*Please return to:*

Lorraine Beinhaur, Human Resources Specialist

USDA NRCS

One Credit Union Place, Suite 340

Harrisburg, PA 17110-2993

Fax: (717) 237-2238

E-mail: <lorraine.beinhaur@pa.usda.gov>