Mentor Application Form, Medtech Consultant, Incubate Startup

Upload ID(only pdf and jpeg and maximum size 5 MB) *

Nationality*

Indian

Other

LinkedIn profile URL

Facebook profile URL

Webpage/Blogpost URL

Highest Awarded Degree*

Your Highest Awarded Degree: *

Area of Specialisation*

Your Area of Specialisation:*

Educational Institute of Highest Awarded Degree*

Year of completion of Highest Awarded Degree*

Year

Languages conversant in*

You are registering as*

Are you employed by any of the AIM partners?*

Yes

Please select the AIM partner

Name of Current Organization*

Type of Organization*

Your Organization Type*

Designation with the Current Organization*

Current Area of Work*

Work Experience with Current Organization*

years

Total Work Experience*

years

Professional Awards (if any)

Do you have any mentoring experience?*

Yes

Amount of experience (in years) for each type :-*

Corporate Environment

Which form of mentoring would you prefer?*

How many hours are you ready to commit per week?*

hours/week

Please select 4 preferred ATLs to mentor :-*

If selected as a mentor, you will be assigned two schools to begin your mentoring journey. AIM, NITI Aayog will try to allocate one school from your below preferences however there is no guarantee that you will be assigned a school from your preference list. The second school will be assigned by AIM for remote and virtual mentoring
Maximum allowed ATL preferences from your own state is 2. Please select a minimum of 2 ATLs outside your state.

Please select 3 areas of contribution

Do you want to mentor a start-up/incubator?*

Yes

Functional Expertise*

Please provide your experience in the following domains :-*

Why do you want to be a Mentor of Change and how will your experience position you to be an effective mentor?*

Referee Phone Number*

How do you know them?*

Is the referee an existing Mentor of Change?*

Yes

Please ensure you are providing referee's AIM registered Email

Referee Phone Number*

How do you know them?*

Is the referee an existing Mentor of Change?*

Yes

Please ensure you are providing referee's AIM registered Email

Where did you first hear about Mentor of Change?*

Please share a challenge that you overcame while mentoring someone (does not have to be a professional mentoring experience, a personal story would also qualify). How did you solve for the challenge? (only video responses upto 1 minute)*

Please share 3 best practices that you would employ to collaborate with the ATL teacher in-charge, school administration and students to create a vibrant community that is conducive to innovation? (only video responses upto 1 minute)*

Mentorship Form

MENTOR MEDIVAllEY- APPLICATION FORM