1. Application for mentors program Agri-business incubator-
ICRISAT Patancheru502 324, Andhra Pradesh, India (NIABI Form I A)
Photo(Note: You can tick multiple choices)Domain areas in which you
would like to mentorAgriculture Horticulture
Agri-inputAgri-processing IncubationDairy FisheryBiotechnology
Agri-engineering otherSpecific details:
___________________________________________________________________________________________Functional
areas in which you would like to
mentorMarketingConsultancyBusinessFund raising
(Angel/VC/Grants/DebtsQuality controlLegal/IPRotherSpecific
details:
___________________________________________________________________________________________PERSONAL
DETAILS Name WORK EXPERIENCE: Please list the name of the
organizations along with the designation, industry type Age have
worked with. you AddressName of DesignationPeriod Specialization
Briefly describe the nature of workorganization (From-To)
Phone(mobile) Email ID Language proficiency Geographical areas
where you want to mentor 1
2. BUSINESS QUALIFICATIONS: Please list any business training
programs or course that you haveundertakenTitle of the training
program OrganizingDuration of the Year of completion
agencytrainingPROFESSIONAL AFFILIATION: Please list any
professional organizations or committees you
areFORMALwith.associated EDUCATION QUALIFICATION: Please detail
here any degrees, diplomas, trade certificatethat you may have.Name
of thePosition in the PeriodBriefly describe the nature of your
work DegreeorganizationPeriodorganizationInstitute/Specialization %
Marks obtainedObtained (From To) university2 3. ACHIEVEMENTS:
Briefly describe your achievements in your career life.1.2.3.4.5. 3
4. ABOUT YOUR BUSINESSCompany nameAddressPhoneYear of operationSole
owner/Partnership/ Pvt.Ltd/ Public Ltd/ OtherIndustry TypeSub area
of BusinessDescribe your business: 4 5. What is your role in
thebusiness?Performance Snapshot:(sales, turnover, profit
etc.)Financial Performance:(Please attach last two yearsfinancial
statement of thebusiness.)ABOUT MENTORING Everyone chooses to
mentor for a variety of reasons. Please give us an insight as to
why you want to be a mentor in this program. Do you have any
previous mentoring experience? Please detail Name of the Field
ofPeriod of AchievementsBriefly describe the work done
duringRemunerations mentoring organizationmentoring Self
satisfactionthe program Recognition Career Advancement Social
Satisfaction Business lead and networking5 6. What skills do you
possess that will add value to the incubatees?1.2.3.4.5.How often
do you want to mentor? Please specify the period.What days/ time
you can devote for the WeeklyDailymentorship program?
MonthlyQuarterlyNumber of days in a week:Half yearly AnnuallyMonday
TuesdayWednesdayThursdayFridaySaturday6SundayAny dayDuration in
terms of hours in a day:
____________________________________________ 7. How do you want to
provide service?Email/Chat Video conferencingWeb CastingPersonal
visitsGroup activities Blogs(E.g. Seminar, workshop
etc)Othersplease specify________________How many free mentorship
sessions you can offer? ________________________Type of incubatees
you want to work with?Established StartupsInnovativeAgri/RuralWoman
Technology basedOtherPlease specify___________________How many
concurrent incubatees you can work with?
_________________________What are your expectations from the
mentee? 7 8. Terms for program Financial terms: Please specify the
fee for mentorship activity as per the mode of mentorship. 1.
Phone:
_______________________________________________________________________
2. Personal Visits:
________________________________________________________________ 3.
Webinars/ Videoconference:
_____________________________________________________ 4.
Email/Chat:
___________________________________________________________________
Time Duration: Please specify the time period you want to be
engaged with the mentoring activity.1 year 2 year 3 year 4 year 5
year More than 5 year Any other terms (financial or time period
terms or both)ReferenceName:Designation :Phone No. :Address
:Enclosures: 1. Photographs 2. Testimonials 8 3. Resume 9.
DeclarationI hereby declare that the above information is correct
and I am willing to take up this assignment and willdischarge all
my responsibilities required thereof.Date: Signature of mentor9
