Mentor Application

All sections must be completed.
If a question does not apply to you please enter N/A for not applicable.
Any questions can be directed to the aforementioned Mentor Coordinator.

Section I: Background Information

Name:

Male: Female:

Home Address:

City: State: Zip Code:

Drivers License No:

Social Security No:

Employer:

Employer Address:

Supervisor's Name:

Length of Employment:

Have you ever been convicted of a crime? (Note: Answering yes to this question will not disqualify you from consideration)

YES NO

If yes please explain:

Can you speak any additional languages?: Yes No:

Section II: References

Please list the names and addresses, and phone numbers of three people that are not related to you that may be uses as character references (please list only people you have known for at least one year

Name:

Address:

City: State: Zip Code:

Home Telephone: Work Telephone:

Relationship:

Name:

Address:

City: State: Zip Code:

Home Telephone: Work Telephone:

Relationship:

Name:

Address:

City: State: Zip Code:

Home Telephone: Work Telephone:

Relationship:

Text Box:

Section III-Mentoring Information

Why do you want to be a mentor? (please attach additional sheet if necessary)

Do you have any previous experience volunteering or working with ex-offenders? Yes No

If so, please explain:

How often can you meet with mentee?

Once per week Once every other week Once a month

What time can you meet with your mentee?

Lunchtime After 5:00 pm Weekends Reg. Bus. hours

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