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*Required Fields
*First Name:

*Last Name:

*Address:

 

Click your preferred method of contact:

*Phone Number:

Fax Number:

Cell Number:

Pager Number:

Email Address:

If Applicable:

 

Current Title:

Company Address:

Company Name:

 

Click your preferred method of contact:

Phone:

Fax Number:

Cell Number:

Pager Number:

Email Address:

Education:

 

1:

Institution:

Degree:

Date:

2:

Institution:

Degree:

Date:

3:

Institution:

Degree:

Date:

What are your reason(s) for contacting the Rick's Place Mentoring Program?
Please mark those from the following that apply.

Consultation:


Other

Career Development:











Occupational Assistance:


Career Search Status:



Assistance needed with:




From the previous checklist, please prioritize your three primary reasons for contacting Rick's Place Mentoring Program.

1:

2:

3:

Additional information:

* What are your expectations of the Mentor Program -- what specific goals do you hope to achieve?

* How long do you think it will take to achieve the above goals?

* What amount of time can you commit to the achievement of your desired goals, e.g., hours per week or per month?

* When are you available to meet and work towards achieving your goals - specific days and times?
(Example: Wednesday evenings from 6:00 p.m. to 7:30 p.m.)

 


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