| *First Name: |
|
| *Last Name: |
|
| *Local Address: |
|
| Permanent Address (if different): |
|
| *Home Phone: |
|
| Cell Phone: |
|
| *Email Address: |
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| In case of emergency contact... |
| *Name: |
|
| *Phone: |
|
| Relation to You: |
|
| *Year in School: |
Freshman
Sophomore
Junior
Senior
Graduate |
| *Expected Year of Graduation: |
|
| *School: |
CAS
SSOM
LAW
NESAD |
| Major: |
|
| Minor: |
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| Cumulative GPA: |
|
| Previous Institutions Attended: |
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Please list the clubs/organizations
you are currently involved with: |
|
Do you work in any other departments
at Suffolk University? |
Yes
No
|
| Which department? |
|
| How many hours per week? |
|
| Why do you want to be a mentor? |
|
Provide two references; at least
one must be a faculty member. |
| Reference #1: |
| *Name: |
|
| *Phone: |
|
| *Email: |
|
| *Department: |
|
| Reference #2: |
| *Name: |
|
| *Phone: |
|
| *Email: |
|
| *Department: |
|
*I agree to complete all necessary
training for this position. |
|
|
|
