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Application Form

Thank you for your interest in the program!

Part I

For Student Applicant

Name:

Telephone:

E-mail:

Major/Intended Major:

Which Year?  2nd     3rd     4th

Ethnicity:   African-American   Asian  Latino  Native American  Other

I prefer a male mentor   female mentor in Department.

I have no preference for mentor's gender 


For Faculty Applicant

Name:

Telephone:

E-mail:

Department:

I prefer a male student female student in major.

I have no preference for student's gender.


Part II

For ALL Applicants

If you have participated in the program before, in which year .

If you want to keep the same mentor or mentee, please write his/her name:
.

My main academic interests

I want my mentor/mentee to know about me