Thank you for agreeing to work with us as we affect change in our students' personal, social, and academic lives. Please complete the following application form and proceed with the Background Check procedures. We will contact you shortly to schedule your interview and orientation.

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* 1. I am applying for:

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* 2. Today's Date

Date

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* 3. First Name:

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* 4. Middle Initial:

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* 5. Last Name:

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* 6. Are you a REACH Memphis (Memphis PREP) Alum?

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* 7. Date of Birth:

Date

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* 8. Gender:

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* 9. Ethnicity

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* 10. Please indicate your t-shirt size.

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* 11. Email Address:

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* 12. Address:

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* 13. City:

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* 14. State:

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* 15. Zip Code:

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* 16. Home Phone:

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* 17. Cell Phone:

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* 18. Driver's License Number:

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* 19. Make of Car:

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* 20. Car Insurance Policy Number:

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* 21. Emergency Contact:

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* 22. Current Employer:

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* 23. Position Held:

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* 24. Company Phone:

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* 25. College 1:

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* 26. Degree 1:

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* 27. Graduation Date 1:

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* 28. College 2:

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* 29. Degree 2:

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* 30. Graduation Date 2:

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* 31. College 3:

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* 32. Degree 3:

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* 33. Graduation Date 3:

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* 34. Reference 1 (first and last name):

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* 35. Reference 1 Phone:

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* 36. Reference 2 (first and last name):

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* 37. Reference 2 Phone:

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* 38. Reference 3 (first and last name):

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* 39. Reference 3 Phone:

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* 40. Languages Spoken Other than English:

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* 41. Were you among the first generation in your family to receive a Bachelor's Degree?

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* 42. Hobbies/Interests:

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* 43. What does mentoring mean to you?

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* 44. Were you ever mentored?  If yes, what was the experience like?

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* 45. Why do you want to be a mentor and what do you hope to accomplish?

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* 46. I certify that the information supplied above is correct and accurate to the best of my knowledge.  I also give permission to contact references and I agree to complete a criminal background check.

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* 47. Please indicate your skill level for each of the following:

  Unskilled Skilled Highly Skilled
Writing
Grammar
Editing
Communications
Math
Science

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* 48. If you could recommend one book for your mentee to read, what would it be?

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* 49. Please place a check in the box indicating that you understand the following:

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