OMB
Control
Number:
2010­
0032
Approval
Expires:
8/
31/
06
SECTION
1
Program
Description:

The
Performance
Track
Mentoring
Program
was
developed
to
facilitate
information
sharing
and
help
applicants
complete
and
strengthen
their
Performance
Track
applications.
The
Performance
Track
Mentoring
Program
is
available
to
any
current
program
member
or
any
facility
that
has
considered
applying
to
the
Performance
Track
program
and
would
like
to
gain
a
member s
perspective
of
the
program
or
is
seeking
personal
assistance
in
setting
environmental
goals
from
top
performing
facilities
currently
in
the
program.
Mentees
are
matched
with
Performance
Track
facilities
that
volunteer
their
time
and
resources
to
share
their
experiences
and
expertise
in
environmental
best
practices.

Instructions:
Please
provide
the
following
information
so
that
we
may
appropriately
match
you
in
the
mentoring
program.
If
you
wish
to
complete
this
form
electronically,
please
use
Times
New
Roman,
10
font.

First
Name:

Last
Name:

Title:

Company/
Org:

Mailing
Address:

E­
mail
Address:

NAICS
Code:

SECTION
2
Please
indicate
whether
you
are
applying
to
become
a
mentor
or
a
mentee:

Mentor
(
If
this
box
is
checked,
please
skip
to
Section
6.)

Mentee
SECTION
3
Briefly
describe
what
your
site
produces
and/
or
its
functions:
Mentoring
Program
Registration
Form
Provide
an
estimate
of
the
number
of
employees
at
your
facility:

SECTION
4
Please
indicate
in
which
areas
you
would
like
your
mentoring
relationship
to
provide
additional
guidance
(
You
may
check
more
than
one
box.):

General
Performance
Track
Information
and/
or
Guidance
EMS
Compliance
Environmental
Commitments
Community
Outreach
SECTION
5
If
your
site
has
been
working
with
a
current
Performance
Track
member,
please
indicate
which
site:

Contact
name:

Contact
Phone:

If
possible,
would
you
like
to
work
with
this
site
as
your
official
mentor?

SECTION
6
Please
indicate
which
characteristics
are
most
important
for
your
mentoring
match
(
You
may
check
more
than
one
box.):

Similar
industry
Geographic
Proximity
Similar
Size
of
Business
Other,
please
specify:

If
more
than
one
characteristic
was
chosen,
please
specify
the
most
important
of
the
above
characteristics:

*
Please
direct
any
question
or
concerns
to
www.
epa.
gov/
performancetrack
or
call
888­
339­
PTRK.
The
public
reporting
and
record
keeping
burden
for
this
collection
of
information
is
estimated
to
average
0.25
hours
per
response.
An
agency
may
not
conduct
or
sponsor,
and
a
person
is
not
required
to
respond
to,
a
collection
of
information
unless
it
displays
a
currently
valid
OMB
control
number.
To
comment
on
this
collection
contact
the
Director,
Collection
Strategies
Division
(
2822T),
1200
Pennsylvania
Ave.
NW,
Washington,
DC
20460.
Include
the
OMB
control
number
in
any
correspondence.
Do
not
send
the
completed
form
to
this
address.
