PEER MENTOR
Application
APPLICANT INFORMATION
Last Name
First
M.I.
Street Address
Apartment/Unit #
City
State
Phone
E-mail Address
Student ID #
ZIP
Overall GPA
Major
Will you have completed at least 60 credits
by start of Fall semester?
YES
NO
Signing up for A&S or Major credits?
Maj
A&S
Have you ever been convicted of a felony?
YES
NO
Have you served as a Peer Mentor
previously?
If major,
course #?
If yes,
explain
EDUCATION
High School
From
City, ST
To
Did you
graduate?
College
(other than
UND)
From
YES
NO
Degree
NO
Degree
City, ST
To
Did you
graduate?
YES
REFERENCES
Please list at least two professional/UND faculty member references.
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
Date
YES
NO
PREVIOUS EMPLOYMENT
Company
Phone
Address
Supervisor
Job Title
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
MILITARY SERVICE
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to service in the program, I understand that false or misleading information in my application or interview
may result in my release.
Signature
Date