Address:

City:

State:

Zip:

Email    Phone

Graduation year Major (1) (2)

Higher education

Career(s) past

Career present

Other interests and hobbies:

Maximum number of students I am willing to mentor (per term):

Maximum interaction (# of contacts per term per student):

Time frame I am available (ie. Fall 2002 to Spring 2003):

Any other information you would like to add: