Apply to be a Rural Mentor

Please complete the following registration form to apply to be a mentor

Please be assured that any information you give in your application is in confidence to the Rural Mentor programme and will only be used for purposes within the Rural Mentor programme.

Required fields are marked with

General

First Name:
Last Name:
Gender:	Male Female

Contact Details

Email address:
Phone:
Mobile:
Fax:

Address

Physical Address: RD No., Town & Postcode
Postal Address: RD No., Town & Postcode

Farm Information

Region:	- Select Region - Northland Waikato Central Plateau Taranaki Gisbourne Hawkes Bay Wairarapa Manawatu Wellington Nelson / Marlborough West Coast Canterbury Otago Southland
Business:	Sole Company Trust Partnership
Industry:	Dairy Sheep & Beef (drystock) Organic
Are you:	Land owner Manager Trustee Leassee Lower order sharmilker Share farmer 50:50 sharemilker Head shepherd Herd manager Shepherd/general hand Farm Worker Other:
How many years in current role:	Years
How many years in current industry:	Years
Do you employ staff:	Yes No
If yes, no. of permanent staff:
If yes, no. of casual staff:
Property Size:
Total	ha
Effective	ha
Runoff area: (dairy, if applicable)
Total	ha
Effective	ha
Estimated cow numbers (dairy) 1st June:
Estimated stock units (drystock) 31st June:
Enterprises:
Sheep
Finishing lambs
Bulls
Deer
Goats
Finishing Beef
Dairy Support
Beef cows
Other:
Your involvement in current industry: Please describe in more details the activities of your business.
Please select category / categories of expertise which best describe your skills:	Strategic/Business Planning Human Resource Manager Farm management Enterprise development Financial planning Budgeting and cashflow Networking Environment Personal development Leasing Farm manager Pasture Management Systems Trading (livestock) Communication Trading (property) Capital growth/wealth creation Other

Other

What factors do you think contribute most to your success? Briefy list your work history
Are you aware of any other factors such as personal, insovency, involvement in an insolvent company or criminal convictions which are relevant to your suitabiliy to act as a mentor?
	Yes No
Why are you interested in being a mentor?

References

Please enter the name of two references who we can contact by phone:
Referee 1:
Name
Phone
Relationship
Referee 2:
Name
Phone
Relationship

Terms & Conditions

I understand the following:
I will need to attend training/workshops put on by the Rural Mentor programme I will update my contact details with the co-ordinator if they change I will inform the co-ordinator if I can no longer be a mentor