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ERROR: Please indicate Mrs. Ms. or Miss

ERROR: Please indicate your first name.

ERROR: Please indicate your last name.

ERROR: Please indicate the name of the institution you represent.

ERROR: For communication purposes, please indicate your language of preference.

ERROR: Please indicate your street address.

ERROR: Please indicate your city.

ERROR: Please indicate one phone number where you can be reached at.

ERROR: Please indicate which means of communications would you prefer using with a mentoree

ERROR: Please indicate number of years in office.

ERROR: Please indicate if you are a Parliamentarian

ERROR: Please indicate if you will be interested in participating in/travelling to face to face meeting of mentors and mentored

ERROR: Please indicate if you would be interested in contributing articles to the FIPA website and newsletter about your experience as women parliamentarian

Personal Information: #form.MrMs# #form.firstname# #form.lastname# #form.typeparliamentarian# #form.rank# #form.parliament# Language: #form.idioma# Español: #form.esp# Portuguese: #form.por# English: #form.ing # French: #form.fran# Other Language: #form.otherlanguage# Address: #form.mail1# #form.mail2# #form.ciudad# - #form.provincia# #form.codpos# #form.Country# Phone number: Office: #form.officephone# - Home: #form.homephone# - Cell: #form.cell# - Other: #form.otherphone# Fax: #form.fax# Email: #form.email1# - #form.email2# Website: #form.website# Years of service: #form.years# Communication: Email: #form.means_email# MSN: #form.means_msn# Phone: #form.means_phone# Fax: #form.means_fax# Other: #form.means_other# Face to face meeting: #form.meetings# Interested in contributing: #form.contribution# Region if interest: #form.region_of_interest# Committee experience: - #form.c_experience_1# - #form.date_1# - #form.c_experience_2# - #form.date_2# - #form.c_experience_3# - #form.date_3# - #form.c_experience_4# - #form.date_4# - #form.c_experience_5# - #form.date_5# - #form.c_experience_6# - #form.date_6# - #form.c_experience_7# - #form.date_7# - #form.c_experience_8# - #form.date_8# - #form.c_experience_9# - #form.date_9# - #form.c_experience_10# - #form.date_10# Positions held: - #form.positions_1# - #form.date_positions_1# - #form.positions_2# - #form.date_positions_2# - #form.positions_3# - #form.date_positions_3# - #form.positions_4# - #form.date_positions_4# - #form.positions_5# - #form.date_positions_5# - #form.positions_6# - #form.date_positions_6# - #form.positions_7# - #form.date_positions_7# - #form.positions_8# - #form.date_positions_8# - #form.positions_9# - #form.date_positions_9# - #form.positions_10# - #form.date_positions_10# Experience: - #form.experience_1# #form.date_experience_1# - #form.experience_2# #form.date_experience_2# - #form.experience_3# #form.date_experience_3# - #form.experience_4# #form.date_experience_4# - #form.experience_5# #form.date_experience_5# - #form.experience_6# #form.date_experience_6# - #form.experience_7# #form.date_experience_7# - #form.experience_8# #form.date_experience_8# - #form.experience_9# #form.date_experience_9# - #form.experience_10# #form.date_experience_10# - #form.experience_11# #form.date_experience_11# - #form.experience_12# #form.date_experience_12# Personal areas of expertise and interest: #form.interest#

Your registration to the Mentorship Program is now complete.

Parliamentary Mentorship Program

Registration form for Women Mentors

Please note that information provided by Mentors will be available online through the Virtual Parliament on the Group of Women Parliamentarian’s Work Space. Access to this space is limited to registered parliamentarians and is not available to the general public.

PDF File

Personal Information

The fields marked with an asterisk * are mandatory.

Mrs. checked> Ms. checked> Miss checked> *

First Name: *

Language of Preference: *

Last Name: *

Languages Spoken :

Parliamentarian: *

Spanish checked> Portuguese checked> French checked> English checked>

Other :

Title: *

Institution: *

Mailing Address : *

City: *
State:
Postal Code:

Country: *

Phone number (s) you can be reached at:*

(Include area code e.g: 613-555-5555)

Office:		Cell.:

Home:		Other:

Fax:

E-mail 1:

E-mail 2:

Website:

Number of years in elected office:

Mentorship Program

A) Which means of communications would you prefer using with the person you are mentoring?

checked> E-Mail
checked> Messenger (MSN, Yahoo, AOL ...)
checked> Phone
checked> Fax

Other:

B) Would you be interested in participating in/ travelling to a face to face meeting of mentors and mentored?

checked> Yes
checked> No

C) Would you be interested in contributing articles to the FIPA website and newsletter about your experience as women parliamentarian?

checked> Yes
checked> No

Are you interested in working with women from a particular country/region and, if so, where?

Experience and Interests

Should you require more space we invite you to send your résumés, biographies and CVs to us by e-mail at info@e-fipa.org

Committee experience:

10.

Date From - To

Positions held during your time in office:

10.

Date From - To

Professional, academic and volunteer experience:

10.

11.

12.

Date From - To

Personal areas of expertise and interest:

For more information contact:

FIPA Technical Secretariat, Canada, Tel: 1 (613) 594-5222, Fax: 1 (613) 594-4766, info@e-fipa.org

Should you have technical difficulties filling out this form, please contact : Technical support