Name

Address

Local Address

City/State/Zip

Local Phone

E-mail

Degree you are working toward and expected completion date

Discipline (i.e., aerospace engineering, electrical engineering, etc.)

Hobbies

Home Address

Hometown/State/Zip

Home Phone

What is your professional goal:

Where do you picture yourself working in five years?

10 years?

Are you looking for a mentor with experience in a specific area, i.e.,
nanotechnology or green chemistry?   
Yes No

If yes, please list your top three areas of interest

Are you looking for a mentor who has experience working in a lab or research setting?
Yes No

If yes, list the area of research or lab equipment/procedures you are most
interested in learning more about

Are you looking for a mentor who is working or has worked in industry,
academia, or for the government? Yes No

If yes, describe preference and how that fits with your goals.

Are you are looking for a mentor in a specific company? Yes No

If yes, list the company(ies) you are most interested in here and why.