PMP - Peer Mentor Program Application

Multicultural
Student Affairs

African American
Student Affairs

Hispanic Student Affairs

Native American
Student Affairs

Peer Mentor Program

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MSA Listservs

Peer Mentor Program Application

The fields that have an * beside them, are required before submitting this form.

Name:
(Last, First Middle Initial)

Ethnicity (optional):

Telephone Phone:
ex. (xxx) xxx-xxxx

Local or School Address:
(Street, Route, or Box Number)

City:

State:

Zip Code:

Most communication for the Peer Mentor Program is done via email. Please indicate the email address that you check most often.

Email Address:

Please indicate any campus disciplinary history (i.e. Student Conduct, Academic integrity, Housing issues etc.)

* Curriculum (Check One That Applies To You)

	Agriculture and Life Sciences		Agriculture Institute
	Design		Education
	Engineering		Management
	Natural Resources		Humanities and Social Sciences
	Physical and Mathematical Sciences		Textiles
	First Year College or University Transition Program

Student ID Number:

GPA:

Major:

Classification:

NCSU Extracurricular Activities:

High School Extracurricular Activities:

Supporting Information

Did you have a Mentor your first year at NCSU?

	Yes
	No

If so, please indicate how you were assigned your Mentor

	Through my college
	Through Multicultural Student Affairs
	I did not have a Mentor

How did you found out about the Peer Mentor Program?

	Banner/Flyer
	Listserv Announcement
	Emailed Invitation
	Student Organization Presentation
	Personal Referral (Please indicate name of person who referred you)

4.	Why are you interested in becoming a Mentor through the Peer Mentor Program?

4.	What pertinent experiences, skills, and/or characteristics qualify you as a Peer Mentor?

5.	Years as a Mentor as of this academic year?

6.	What career/occupational goals are you interested in pursuing upon graduation?

7.	Additional Information: Use the space below to make any additional comments.

NC State University's Non-Discrimination Policy

It is the policy of the State of North Carolina to provide equality of opportunity in education and employment for all students and employees. Accordingly, the university does not practice or condone unlawful discrimination in any form against students, employees or applicants on the grounds of race, color, religion, creed, sex, national origin, age, disability, or veteran status. North Carolina State University regards discrimination on the basis of sexual orientation to be inconsistent with its goal of providing a welcoming environment in which all its students, faculty, and staff may learn and work up to their full potential. The University values the benefits of cultural diversity and pluralism in the academic community and welcomes all men and women of good will without regard to sexual orientation.

Last Updated: August 17, 2008