Name:

Date:

Academic degrees and majors (years & institutions) :

Employer:

Office address:

Office phone #:

Home address: (used only by the School of Business for contact purposes)

Home phone #: (used only by the School of Business for contact purposes)

Cell phone #:

E-mail address:

Job title:

Industry:
Aerospace & Defense
Airline
Automotive
Consumer Goods & Services
Energy
Financial Services
Government
Health & Life Sciences
Manufacturing
Media & Entertainment
Non-Profit
Retail
Technology
Travel
Other

Area of specialization:
Sales
Marketing
Finance
Accounting
Human Resources
Other

Number of years in industry:

Job description (please elaborate):

Comments (appropriate attire for visiting students, your availability, etc.):

Please indicate which of the following you are willing to provide:
Career information (e-mail correspondence)
Career information (telephone interview)
Career information (in person interview)
Host a student during a typical half or full work day
Other (i.e., internships, speaking to classes, student clubs)

Thank you for your interest in the Career Mentorship Program