*1.First Name(Required.)

*2.Last Name

(Required.)

*3.Contact Information(Required.)

Address *

Address 2

City/Town *

State/Province *

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code *

Country

Email Address *

Phone Number *

*4.Which race/ethnicity best describes you? (Please choose only one.) (Required.)

African American

Asian American

Asian/Indian Subcontinent

Hispanic/Latino

Mexican American/Chicano

Native American

Native Hawaiian/Pacific Islander

Puerto Rican

White/Caucasian

Multiple ethnicity / Other (please specify)

*5.Name of the 2 or 4 year college/university you are currently enrolled in(Required.)

*6.Anticipated Graduation Year(Required.)

*7.What is your major?(Required.)

*8.Location of High School you graduated from(Required.)

City/Town *

State/Province

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

Country *

*9.Hometown zipcode (enter 00000 if you are an international student)(Required.)

*10.Describe your interest in a building a career in tech(Required.)

*11.Have you had an internship or job in tech?(Required.)

Yes

No

12.If yes, where?

*13.Are you currently involved in any clubs or organizations focused on tech? Please describe.(Required.)

*14.What do you hope to gain from participation in this mentorship program?  (Required.)