PVAMU College of Business
IMPACT Mentor Application
(Please type or print in black ink.)
Salutation:
Dr.
Mr.
Mrs.
Ms.
Name:
_____________________________________________________________________________________
First Name
Last Name
Preferred Contact Address
Home
Office
____________________________________________________________________________________
Address
____________________________________________________________________________________
Mail Code/Stop: _____________________
_____________________________________________________________________________________
City
Phone:
State
Home
Office
Mobile
(
Zip
) _________________________ext. ________
E-mail: ______________________________________________________________________________
May we contact you by e-mail? (event reminders, etc.) Yes
No
Employment
Employer: ______________________________________________________________________
Job Title:_______________________________________________________________
Length of time with this employer: ______________ (Years
Months)
Education
Undergraduate School: __________________________________________________________________
Undergraduate Major: _________________________ Undergraduate Minor: ______________________
Undergraduate Clubs, Activities or Affiliations:
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Graduate School: ______________________________________________________________________
Graduate Degree: ______________________________
Graduate Clubs, Activities or Affiliations:
Graduate School: ______________________________________________________________________
Graduate Degree: ______________________________
Graduate Clubs, Activities or Affiliations:
Optional Demographic Information
Ethnicity (Optional):
_____ African American/Black
_____ American Indian or Alaskan Native
_____ Asian or Pacific Islander
_____ Hispanic/Latino
Gender:
____ Pan African
____ White/Caucasian
____ Multiracial
____ Other: _____________________________
_____ Female _____ Male
Mentor Information
Have you served as a mentor before?
Yes
No
Why would you like to participate in this program?
What personal experiences, skills, values and/or knowledge would you particularly like to pass onto your
protégé? Provide information which would be of use in developing a mentoring relationship. (e.g.
career planning, personal guidance, etc.)
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Please describe your job(s). Be as specific as you can; include title, areas of expertise, and your work
environment.
Please indicate any specific requests or requirements you may have regarding your involvement in the
program (i.e., limited hours available, available only during working hours)
Is there a particular type of student that you prefer to work with? Yes
No
If so, please list any preference(s) about your protégé which we should take into account? (e.g. major,
background, gender, etc.)
What kind of support/assistance can the program offer that will be most helpful to you?
Describe any special interests you would like to share.
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How many protégés would you feel comfortable working with?
(Circle one.) 1 2 3
Would your protégé be able to visit your workplace?
No
Yes
What are the best times for you to meet? Please circle the times you prefer:
Weekday Morning
Weekend Morning
E-mail/Online Only
Weekday Afternoon
Weekend Afternoon
Weekday Evening
Weekend Evening
Please indicate your area(s) of experience. Check as many boxes as are applicable.
Advertising
Accounting
Business (Management)
Communications
Education (K - 12)
Engineering
Entertainment
Event Planning
Entrepreneurship
Financial Services
Healthcare Management/Public Health
Higher Education (Administration)
Higher Education (Faculty)
Hospitality
Human Resources
Information Systems/Information Technology
Insurance
Law
Marketing
Music/Entertainment
Non-Profit
Operations/Logistics
Personal Financial Planning
Project Management
Public Speaking/Public Relations
Public Policy/Government
Publishing
Real Estate
Research
Retail
Sales
Small Business Ownership/Management
Social Services
Supply Chain
Technology
Writing/Film/Art
Other:
______________________________________________________________________________
______________________________________________________________________________
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References
Please provide contact information for at least 2 references
Reference 1
Name:
_____________________________________________________________________________________
First Name
Last Name
Relationship to Applicant: _______________________________________________________________
Phone:
Home
Office
Mobile
(
) _________________________ext. ________
E-mail: ______________________________________________________________________________
Reference 2
Name:
_____________________________________________________________________________________
First Name
Last Name
Relationship to Applicant: _______________________________________________________________
Phone:
Home
Office
Mobile
(
) _________________________ext. ________
E-mail: ______________________________________________________________________________
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PVAMU College of Business
IMPACT Mentor Agreement
Fall 2015 Application Deadline: November 4, 2015
Coordinators will make every attempt to match students and professionals in their chosen career fields.
This is a pilot program and the number of individuals selected will be limited. All mentors and students
are encouraged to discuss academic and career-related issues, such as selection of major, networking,
business etiquette, interviewing and job search techniques regardless of your career interests.
PVAMU College of Business mentors who apply and submit an application understand that participation
in IMPACT is a privilege. By signing this form and submitting an application to this program, I agree to
the following:
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Participate in any required workshops and/or training related to the IMPACT program.
Meet at a minimum during one of two PVAMU-sponsored IMPACT Events scheduled in Fall 2015 (IMPACT
Orientation Meeting, Wednesday, November 11, 2015 at 6:00 p.m.) and/or Spring 2016 semester.
Be committed to work carry out agreed upon goals.
Expect to contact or meet with protégé 1-2 times per month
Notify one of the program coordinators if unable to engage with protégé
Keep discussions confidential, unless student’s safety or well-being is at risk
Ask a College of Business coordinator when needing assistance or clarification during the mentoring
process
Notify the program manager of any significant change in protégé
Contact one of the coordinators if there is a concern about the mentor relationship or with any other
concerns. Inappropriate behavior towards any mentor or program participant may result in being denied
further access to this program.
Notify staff of one of the coordinators immediately if there is a change in your ability to participate in the
program.
At the end of the mentoring period, I understand that I may decide to extend the mentoring period, but
am not obligated to do so. Additional information including expectations will be provided during the
orientation meeting in November.
Print Name
Signature
Date
Return the application and signed agreement form by mail or e-mail to:
Prairie View A&M University
College of Business - IMPACT Program
P.O. Box 519; MS 2300
Prairie View, TX 77446
Phone 936.261.9200
IMPACT Coordinators:
Mr. Danny Harvey
djharvey@pvamu.edu
936.261.9221
Mr. Cleveland Stiff
ccstiff@pvamu.edu
936.261.9263
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