Mentor Applications

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	Maureen Quinn, (H) 609-279-0605 (C) 609-712-3753 546 Keefe Road Lawrence, NJ 08648

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MENTOR APPLICATION

To apply to become a mentor it is very simple - please complete the following 2 steps:

First complete the application form below and click submit.

Second please complete this form (we ask you to do this separately for security reasons) with your Social Security Number and Driver's License details and mail/fax the application to:

Executive Director Maureen Quinn
Maureen Quinn,
(H) 609-279-0605
(C) 609-712-3753
546 Keefe Road
Lawrence, NJ 08648
Email: Njenquinn@aol.com

Date of Application:
Name:
First	Middle	Last
Address:
City, State, Zip	City	State Zip
Telephone	Home Ph Cell Ph	Alternate Ph
Email Id
Work Information:	Title	Organization
Work Address:	PO Box City	State Zip
Work Address:	Work Ph Extn	Work Email
How did you hear about MentorPower?
What motivated you to become a mentor?
Have you participated in any other activities as a mentor? If yes, please describe activities.
Do you have a preference for an environmental project? If yes, state your preference
Do you speak any other languages other than English? If yes, please state them
References: 1: Immediate Supervisor
Name	Title	Work Phone:
References: 2: Any
Name	Title	Work Phone:
Mentor Bio Information
Place of Birth	Hobbies/Leisure Interest	College/University
If there is anyone that you can recommend to our mentor program, please give his or her name, phone number and address as you know it.
Name	Phone No.	Address
* All information youhave provided including all sensitive information you have provided is for Mentorpower NJ's records and will not be shared with any other party whomsoever.