The Iowa Bar Association Mentor Program – Mentor Application

ISBA Member #		Year Licensed in Iowa:

Full Name:		Employer/Firm Name:

Street Address:		City:

State:		Zip Code:

Phone:		Email:

Judicial District:		Other Jurisdictions:

Please select up to three areas which best describe your practice:
Admin/governmental Agriculture/food Antitrust Arbitration/mediation Bankruptcy Business/commercial Construction Criminal Elder Employment/labor law Environmental Family/Domestic Federal practice General practice General litigation Health Immigration Intellectual property International Juvenile Practice management Personal injury /property damage Probate/trust/estate Real estate/title law Social security Tort and insurance Taxation Traffic Trade regulation Trial work Workers compensation

Type of Practice: Solo Practice Law Firm Government Office Judge In-House Corporate Counsel Non-Legal Job		Number of Attorneys:

Other:


MENTOR REQUIREMENTS (Please check all that apply) Must meet all requirements to serve as a mentor):

I am an attorney licensed in Iowa and in good standing (or retired while in good standing). I have been admitted to practice law in Iowa for at least five years. I have a reputation among judges and peers in the local legal community for competence and ethical and professional conduct. I have never been suspended or disbarred from the practice of law in any state nor voluntarily surrendered my license to dispose a pending disciplinary proceeding. I have not been otherwise sanctioned in any jurisdiction in the last ten years. There is no formal disciplinary complaint currently pending against me before the Iowa Supreme Court. I carry professional liability insurance, if required as part of my practice.

About You The following information will be used to create a Mentor profile that will be accessible only to those involved in the pairing process. Personal questions (e.g. inquiries regarding marital status, children, etc.) are optional, but are helpful to ensure we have information to help make successful matches on both professional and personal levels. This information is not designed to serve as “preferences” for a Mentee. If you have preferences related to personal characteristics or other data (such as location), you may indicate those requests later in the application. A separate “Confidential” information section is found at the end of the application, and any information provided there will be used by the Committee to help make a match but will not be provided to individuals outside the Committee, including the Mentee.

Undergraduate School:

Year of Graduation:		Major(s):

Law School:		Year of Graduation:

Other Education:

Degree:		Year of Graduation:

Date of Birth:

Bar related activities:

Civic activities:

Hobbies and interests:

Additional relevant information:

Pro Bono:

Check any of the following skills you posess: Appeals Computer/Technology Research Law Practice Management Regulatory board appearances Ability to discuss substance abuse and mental health issues Ability to be a resource for involvement in bar activities Ability to be a resource for involvement in pro bono activities Ability to assist with assessing career path Ability to advise on balancing career and home life Ability to discuss handling law school debt


I would like to mentor the following attorney (if known)*

Name:		Email/Phone:

Do you have any requests or preferences for your ideal mentee? (i.e. distance/location/type of practice)**


Confidential information

Disability? Yes No		If yes, please describe:

Are you married? Yes No		Do you have children? Yes No

Race:		Sex: Male Female Transgender

Sexual Orientation: Heterosexual Lesbian/Gay/Bisexual Other

Confidential comments regarding a match/preference:


*Please review the information on the next page and sign to complete your application* * Match requests must still meet general program requirements (i.e. not a member of the same firm) and will be honored if possible, but are not guaranteed ** Preferences will be taken into consideration, but the program cannot guarantee that all preferences will be met with each match By completing and submitting this application to mentor in the Iowa State Bar Association Mentor Program, I am acknowledging that: I wish to participate as a mentor in the Iowa State Bar Association Mentor Program in accordance with its rules and regulations. I acknowledge that the information submitted herein is complete and accurate to the best of my knowledge. I certify that I meet all of the Mentor requirements that I checked above. If after I become an approved Mentor, I become subject to a public or formal disciplinary proceeding by any court or bar related entity and/or am formally sanctioned in any jurisdiction, I will notify the Mentor Program Committee. I understand that the Mentee to whom I am matched is determined and approved by the Mentor Program Committee and that there is no guarantee that I will be matched to a Mentee. I understand that this is a one-year commitment, and that should I elect to continue to participate in the program I will need to update my application and indicate my renewed interest to the Mentor Program Committee. I agree to make the necessary time commitment to maintain a mentorship relationship. If my work or life circumstances change so that I cannot be involved in the program, I will contact the Mentor Program Committee. I agree to read the orientation materials that will be provided to me and watch the training video or participate in a live training session. I understand that the ISBA Mentor Program creates a professional relationship. It does not contemplate and is not intended to create a formal association or attorney-client relationship between Mentee and Mentor and does not remove the need to be concerned with confidential or privileged information. I understand that all information provided to the Iowa State Bar Association in this application will be kept private although it may be shared within the Iowa State Bar Association to administer the program and with the Mentee, except that “Confidential” information will not be shared with the Mentee.

Please check this box and type your name to confirm agreement with the terms above.
I accept these terms		Type name to complete:

Questions can be directed to the Committee via Email: mentorprogram@iowabar.org