be a mentor program
M E N T O R  A P P L I C A T I O N
Confidential Application For Volunteers
(Please print or type all information.)

Please complete the following questionnaire:

Name:		Birthdate:	

Ethnicity:		Gender:	

Marital Status:		Spouse/Partner's Name: 	

Number of Children:		Ages of Children:	

Company Name:		President:	

Work Address:		City/State/Zip:	

Work Phone:		Fax:	

Current Occupation:		Hours of Employment:	

Home Address:		City/State/Zip:	

Home Phone:		E-mail:	

Best time to be contacted:		May we call you at work?	

How did you hear about The Mentor Project?	

Have you ever been convicted of a crime or are you currently released on bail, or on your own recognizance for any crime? 	____Yes	____No

Have you been convicted for driving under the influence in the past 10 years (DUI)?       ____Yes            ____No

Do you object to our checking with appropriate authorities such as the Department of Justice, Federal Bureau of Investigation and the California Department of Motor Vehicles for matters of public record regarding your background and history? Please indicate with a yes or no and initial.

Please list the names and complete addresses of three unrelated references, one of which is a work reference. (References will have known you at least two years and are willing to discuss your character, reputation, and ethics.)

1.  Ms./Mr. ………………………………………………………………………………………………………………………..				
	      Name	           Address	      City/State/Zip
    Business (if a business reference)  ……………...……………………………..Phone: ………………………….

2.  Ms./Mr. ………………………………………………………………………………………………………………………..					
	      Name	           Address	      City/State/Zip
    Business (if a business reference)  ……………...……………………………..Phone: ………………………….			

3. Ms./Mr. ………………………………………………………………………………………………………………………...				
	      Name	           Address	      City/State/Zip
   Business (if a business reference)  …………………………………….....….…Phone: ……………….................

	M E N T O R  P O L I C Y  A N D  P R O F I L E 

The above information is true to the best of my knowledge. I understand that I am not obligated, if called upon, to perform volunteer mentor services herein applied for, and that the agency is not obligated to assign, or actively seek to assign, a student to the applicant. I further agree to allow the staff of Students In Business, Inc. and The Be A Mentor Program to elicit additional pertinent, personal information as part of the matching process.

In the event that I am chosen to mentor a youth, I agree to the commitment and to participate to the best of my ability. I will honor confidential information regarding my student. I will be free of the influence of alcohol or illegal drugs when with students on or off school grounds. I will inform the Project Coordinator of any changes in my address and/or phone numbers. I will inform the Project Coordinator in advance should I choose to stop volunteering.

Mentor Signature		Date	

*Please provide a copy of your driver’s license and proof of auto insurance.

Auto Insurance Carrier:		Exp. Date:	

Please write in the State and County where you are willing to serve a student.	

Do you know someone else who might be interested in being a mentor?

Name:  	

Address:		Phone	

Please return to:
Kathy Morrison, Mentor Services Manager
Students In Business, Inc., 4588 Peralta Blvd., Suite 17, Fremont, CA 94536, (510) 795-6488 ext. 6175
Or FAX to (510) 795-6498

	Students In Business, Inc. does not discriminate on the basis of
	race, creed, educational level, physical disability, age, gender, sexual orientation, or marital status.