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Semester

Date

Full Name

First NameLast Name

Student ID#

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail Address

Home Phone

Format: (000) 000-0000.

Mobile

Format: (000) 000-0000.

Classification

GPA

College Major

College Credit Hours Earned

Degree

Other

Please list any special interest, skills, or hobbies

Favorite/least favorite things about college

What topics would you like to address/discuss with a mentor?

What are your expectations for this program?

Please select the words which describe your personality:

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