MENTOR APPLICATION

MENTOR APPLICATION


THE BE A MENTOR PROGRAM M E N T O R A P P L I C A T I O N Confidential Application For Volunteer

Name:	Joan Smith	Birthdate:	01/05/1968
Ethnicity:	Caucasian	Gender:	F
Marital Status:	Married	Spouse/Partner's Name:	Dennis Talbot
Number of Children:	0	Age of Children:

Company Name:	TECHNET	President/Supervisor:	Stewie Wonder
Work Address:	1001 Stoneridge Mall Rd	City/State/Zipcode:	Pleasanton, CA 94555
Work Phone:	925-400-3000	Fax:	925-400-3001
May we call you at work?:	Yes
Current Occupation:	Systems Analyst	Hours of Employment:	8-5

Home Address:	5000 Ralf Ranch Drive	City/State/Zipcode:	Fremont, CA 94987
Have you lived in the state entered above consecutively for the past 10 years? ___

Home Phone:	510-987-1234	Cell Phone:
E-mail:	johnsmith@sib.com	Best time to be contacted:	daytime using work number
Other Languages:

How did you hear about the Be A Mentor Program?
The "VolunteerMatch" website.

Have you ever been convicted of a crime or are currently released on bail, or on your own recognizance for any crime? No

Have you ever been cited for driving under the influence (DUI)? 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. No

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. Mr./Ms. Scot  Pippen

     Pleasanton, CA  94555 Phone: 925-500-5000

2. Mr./Ms. Helen  Wong

     Pleasanton, CA  94666 Phone: 925-666-7777

3. Mr./Ms. Angelina  Stroble

     Oakland, CA  94666 Phone: 510-444-2222

MENTOR POLICY AND PROFILE

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 and the Mentor Project 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 numbers. I will inform the Project Coordinator in advance should I choose to stop volunteering.

Mentor Signature: ______________________________________________     Date: ____________________

Mentor Name: Joan Smith    [X]
   [   ]   I Accept.
I Do Not Accept.

PLEASE FAX THIS PAGE TO BE A MENTOR PROGRAM
SO THAT YOUR SIGNATURE IS ON FILE
FAX NUMBER - (510) 795-6498

*PLEASE PROVIDE A COPY OF YOUR DRIVER'S LICENSE AND PROOF OF AUTO INSURANCE.

Driver License Issuing State: CA Expiration Date: 01/05/2006

Auto Insurance Carrier: Liberty Auto Expiration Date: 6/1/2006

SELECTED PROJECTED

1.  Alameda

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

    Name:

    Address:

    City/State/Zipcode: ,

    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.

Be A Mentor Program Contract Application

How did you hear about the Be A Mentor Program? The "VolunteerMatch" website.

Have you ever been convicted of a crime or are currently released on bail, or on your own recognizance for any crime?	No

Have you ever been cited for driving under the influence (DUI)?	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.	No

1. Mr./Ms.	Scot Pippen
	Pleasanton, CA 94555	Phone:	925-500-5000

2. Mr./Ms.	Helen Wong
	Pleasanton, CA 94666	Phone:	925-666-7777

3. Mr./Ms.	Angelina Stroble
	Oakland, CA 94666	Phone:	510-444-2222

Mentor Signature:	______________________________________________	Date:	____________________
Mentor Name:	Joan Smith	[X] [ ]	I Accept. I Do Not Accept.

Driver License Issuing State:	CA	Expiration Date:	01/05/2006
Auto Insurance Carrier:	Liberty Auto	Expiration Date:	6/1/2006