
Mentor Application
Please
return to:
AJCOP
Chaver Mentoring Program, 14619 Horseshoe Trace, Wellington, FL
33414, by fax 561-798-0358 or by email to lou@ajcop.org.
I.
Personal Data
Name:
_________________________________________________________ Age: _________
Home
Address: _______________________________________________________________
City:
_________________________________State: ___________ Zip Code:
______________
Home
Phone Number: ________________________ Business Number:
__________________
Cell
Phone Number: __________________________ E-mail:
___________________________
How
did you hear about the AJCOP Chaver Program?
________________________________
Please
indicate times available for an interview during the week:
(Interviews may be scheduled from 9:00 a.m. through 5:00 p.m.
(Eastern Time): ____________________________________
II.
Education/Employment:
(Please attach most recent resume).
If
currently employed, name of employer:
___________________________________________
Employer
Address: ____________________________________________________________
Position/Title:
________________________________________________________________
Work
Schedule: ______________________________________________________________
College(s):
_____________________________________ Degree: ______________________
_____________________________________ Degree:
______________________
_____________________________________ Degree:
______________________
_____________________________________ Degree:
______________________
III.
Interests/Personal
Hobbies:
____________________________________________________________________
____________________________________________________________________________
Other
volunteer activities:
_______________________________________________________
____________________________________________________________________________
Briefly,
why do you want to be a mentor?
___________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Can
you make a minimum commitment of one year?
__________________________________
Please
list your areas of
expertise:_________________________________________________
_____________________________________________________________________________
If
paired with a mentee, will you be able to meet AJCOPs requirements of
weekly personal or telephone contact for the first two months and twice
monthly contact thereafter? ____________
____________________________________________________________________________
Do
you have restrictions and/or preferences regarding the mentee you will
be matched with? If so,
please specify:
_____________________________________________________________
____________________________________________________________________________
I
hereby certify that all information contained in this application is
true.
______________________________________
_______________________
Applicant
Signature
Date
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