Submit Mentor Application

Apply to be a Mentor

First name*

Last name*

Maiden name (if applicable)

Contact phone*

Contact email*

Job title*

Company name*

Current Work Address

Street Address

City

State

Zip

Current Home Address

Street Address

City

State

Zip

Previous Addresses

Please list all residences for the past five years, starting with the most recent:

Address 1

Street Address

City

State

Zip

Address 2

Street Address

City

State

Zip

Address 3

Street Address

City

State

Zip

References

Reference 1

First name

Last name

Contact phone

Contact email

Reference 1 relationship

Family, Friend, Employer, etc

Reference 2

First name

Last name

Contact phone

Contact email

Reference 2 relationship

Family, Friend, Employer, etc

Reference 3

First name

Last name

Contact phone

Contact email

Reference 3 relationship

Family, Friend, Employer, etc

Questions for Mentor

Why do you want to take part in this program?

Have you ever had experience working with or operating small businesses? If yes, please specify your role:

Have you ever been involved as an owner, employee, or investor in a startup of a new business? If yes, please specify your role:

What do you do currently? Briefly explain your current job responsibilities:

Consent and Signature

I want to serve as a mentor for the Muncie Regional Mentorship Hub. I understand that as part of the screening process, a criminal background check may be conducted prior to acceptance into the program.

Please print your full name below as your signature:*