Mentor Application – Phi Beta Kappa

Name *

Date *

Email *

Telephone *

1. My area of interest/expertise for a potential mentee is:

Academia (list discipline):

Academia discipline

Medicine (list speciality):

Medicine Speciality

Law (list speciality):

Law speciality

Entrepreneurship (list type):

Entrepreneurship type

Business (list type):

Business type

Government Service (list field/department):

Government Service field/dept

Life Skills (list area):

Life Skills area

Other (please specify):

Other area specifics

2. My preferred method of contact with a new member is: *

Telephone

Email

3. For how long are you willing to be a mentor? *

6 months

6 months – 1 year

1 to 2 years

4. I am willing to serve as a mentor for the following number of new members: *

1

2

3

4 or more