Executive Mentor Application

Contact Information

Name

Prefix First Middle Last

Gender

Male
Female

Church Denominational Affiliation

Company (present or most recent)

Title (present or most recent)

Industry (present or most recent)

Mailing Address

(Please use Work or Home address.)

Street Address City State / Province / Region ZIP / Postal Code Country

Work Phone

Mobile Phone

Preferred Email Address

Professional Information

Areas of Expertise

Do you have more than 7 years of work experience since attaining your undergraduate degree?

Yes
No

Academic Information

Undergraduate University Name

Undergraduate Degree Earned

Year Earned

Graduate University Name

Graduate Degree Earned

Year Earned

Postgraduate University Name

Doctoral or Other Degree Earned

Year Earned

Other Relevant Education, Training, and Experience

Would you prefer to upload a copy of your CV/Resume/Bio here, or provide us with a link to your LinkedIn Profile or Bio page?

Upload a copy of CV/Resume/Bio
Copy and paste the URL to LinkedIn Profile or Bio page

CV/Resume/Bio Upload

Please upload your CV, resume, or bio as a Word document (.doc or .docx) or PDF here.

Accepted file types: doc, docx, pdf, Max. file size: 20 MB.

LinkedIn Profile or Bio Page URL

Please copy and paste the URL to your LinkedIn Profile or bio page here.

Hobbies/Interests/Community/Church Involvement

Mentor Program Information

What are your goals and anticipated benefits of being part of this program?

I prefer to mentor a student who has/is pursuing a degree(s) in

(check all that apply)

Student Mentee Preference

No Preference
Female
Male

The following person has recommended me for this program:

Referrer Name

First Last

Referrer Title

Referrer Company

Referrer Email Address

Referrer Phone

Would you be interested in any of the following?

(check all that apply)

Guest speaker (class or university event)
Serving on the Dean’s Advisory Council

By checking this box and submitting this application, you acknowledge that the information is true and accurate to the best of your knowledge.

Yes, the information on this application is true and accurate to the best of my knowledge.

Signature

Date

Phone

This field is for validation purposes and should be left unchanged.