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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: Indique por favor qué medios de comunicación preferiría usar con su madrina

ERROR: Please indicate the date elected to 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

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# Date elected to office: #form.years# Communication: Email: #form.means_email# MSN: #form.means_msn# Phone: #form.means_phone# Fax: #form.means_fax# Cell: #form.means_cell# Other: #form.means_other# Face to face meeting: #form.meetings# Interested in contributing: #form.contribution# Region if interest: #form.region_of_interest# 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 Seeking Parliamentary Mentorship

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:

Date elected to office:

Mentorship Program

 

A) Which means of communications would you prefer using with your mentor?

checked> Email
checked> Messenger (MSN, Yahoo)
checked> Fax
checked> Phone

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?

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


Professional, academic and volunteer experience:

1.

2.

3.

4.

5.

6.

7.

8.

9.

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