MENTOR APPLICATION Name* First Middle Last SSN#*ACADEMIC RANK*ACADEMIC DEPARTMENT*OFFICE MAILING ADDRESS* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OFFICE PHONE*OFFICE FAX NUMBERHOME ADDRESS* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HOME PHONE*HOME FAXEmail HAVE YOU PREVIOUSLY SERVED AS A UNCF/MELLON MENTOR?*YesNoIf YES, PLEASE PROVIDE THE NAME(S) OF THE STUDENT(S) YOU MENTORED.Please describe your interest in serving as a UNCF/Mellon Mays Undergraduate Fellows’ Mentor and how the student’s research interest compliments your areas of scholarship. Please also describe how you will structure your interactions (i.e., independent study, weekly meetings, etc.) with the fellow. Please also speak to the student’s character traits that you believe will sustain him or her as a representation of your institution and the UNCF/Mellon programs.PLEASE ATTACH YOUR MENTOR’S STATEMENT TO THIS FORM Drop files here or Accepted file types: (jpg, gif, png, pdf). NAME OF APPLICANT WHOM YOU WILL MENTORI HAVE READ THE RESPONSIBILITIES ASSIGNED TO A UNCF/MELLON MENTOR AND I AM PREPARED TO SERVE IN THIS CAPACITY. I HAVE PROOFREAD THIS NOMINEE’S PERSONAL STATEMENTS (RESEARCH AND CHARACTER STATEMENTS) AND APPROVE OF THEM FOR SUBMISSION WITH THIS APPLICATION.SIGNATURE OF MENTOR* First Last Date Date Format: MM slash DD slash YYYY Please attach an abbreviated curriculum vita (NO MORE THAN TWO PAGES)*