PVAMU College of Business
IMPACT Protégé Application (Pre-Business: Freshmen & Sophomores)
(Please type or print in black ink.)
Salutation:
Mr.
Mrs.
Ms.
Name:
_____________________________________________________________________________________
First Name
Last Name
Preferred Contact Address
Home
School
____________________________________________________________________________________
Address
_____________________________________________________________________________________
City
Phone:
State
Home Cellular (
Zip
) ________________________ ext. ________
E-mail: ______________________________________________________________________________
May we contact you by e-mail? (Event reminders, etc.) Yes
No
May we contact you by text? (Event reminders, etc.)
No
Yes
Education
Undergraduate Major: _________________________ Undergraduate Minor: ______________________
Grade Point Average: _________________________
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
IMPACT Pilot Program - 2015
Protégé Application - Page 1 of 4
Protégé Information
Why would you like to participate in this program?
Please describe what you want to accomplish during your time at PVAMU – your academic goals. Be as
specific as you can.
What kind of support/assistance can your mentor provide that will be most helpful to you?
Describe any special interests you would like to share. For example: family life; cultural, hobbies;
volunteer activities
What are the best times for you to meet? Please check the times you prefer:
Weekday Morning
Weekend Morning
Online/E-mail
Weekday Afternoon
Weekend Afternoon
Weekday Evening
Weekend Evening
IMPACT Pilot Program - 2015
Protégé Application - Page 2 of 4
Please indicate your area(s) of interest. 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:
___________________________________________________________________________
IMPACT Pilot Program - 2015
Protégé Application - Page 3 of 4
PVAMU College of Business
IMPACT Protégé Agreement
Fall 2015 Application Deadline: October 30, 2015
Interviews scheduled the week of November 2nd
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 students ("protégés ") requesting a mentor agree that participation in IMPACT
is a privilege. By signing this form and submitting an application to this program, I agree to the following:
 Participate in any required workshops and/or training related to the IMPACT program.

Meet at the fall IMAPCT Orientation Session at 6:00 p.m. Wednesday, November 11, 2015 and at least one
of two PVAMU-sponsored IMPACT Events scheduled in Spring 2016 semester.



Be committed to carry out agreed upon goals.
Contact your mentor in a timely manner if you are unable to attend scheduled meetings.
Expect to contact or meet with mentor 1-2 times per month in keeping with guidelines. I think
we set minimum of twice a month
Protégés should schedule meetings with mentors for no longer than 30 minutes, unless the
mentor agrees to a longer meeting.
Contact one of the coordinators if there is a concern with your 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.
Understand that the PVAMU Code of Student Conduct may apply to inappropriate behaviors
and activities that occur not only on the PVAMU campus, but also away and off-campus.
Notify staff of one of the coordinators immediately if there is a change in your ability to
participate in the program.




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
IMPACT Coordinators:
Mr. Danny Harvey
djharvey@pvamu.edu
936.261.9221
Mr. Cleveland Stiff
ccstiff@pvamu.edu
936.261.9263
IMPACT Pilot Program - 2015
Protégé Application - Page 4 of 4