Fillable EMP Mentor Application Fillable (University of West Florida)

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EMP Mentor Application Fillable (University of West Florida)

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The EMP Mentor Application Fillable (University of West Florida) form is 4 pages long and contains:

  • 2 signatures
  • 30 check-boxes
  • 55 other fields

Country of origin: US
File type: PDF

U.S.A. forms for University of West Florida

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Thank you for your interest in the Executive Mentor Program. This application allows us to successfully
match our students with experienced executives.
Contact Information
Salutation: _____ (Mr., Mrs., Ms., Dr.) First Name: _____________________MI: ______ Last Name: _______________________
Gender: Male Female
Company:______________________________________________________________________________________________________________
Title:____________________________________________________________________________________________________________________
Industry:_______________________________________________________________________________________________________________
Work Mailing Address ______________________________________________________________________________________________
City:_______________________________________ State:______________ Zip Code:__________________________________________
Home Mailing Address _____________________________________________________________________________________________
City: _______________________________________ State: _____________ Zip Code: _________________________________________
Work Phone ____________________________________________________ Fax _______________________________________________
Cell Phone: ______________________________________________________ Home Phone: ___________________________________
Preferred Email Address: ________________________________________________________________________________________
Professional Information
Areas of Expertise: ______________________________________________________________________________________________
____________________________________________________________________________________________________________________
Do you have more than 10 years of work experience since attaining your undergraduate degree?
Yes No
Academic Information
Undergraduate University Name: ______________________________________________________________________________
Undergraduate Degree Earned: ____________________________________________________ Year: ____________________
Graduate University Name: _____________________________________________________________________________________
Graduate Degree Earned: ____________________________________________________________ Year: ____________________
Other Relevant Education: ______________________________________________________________________________________
Bio/Resume/LinkedIn Profile Please attach a copy to this application attached
1 of 3
UWF College of Business | 11000 University Parkway | Pensacola, FL 32514
Ethnicity: (optional) (Please check all that apply)
Hispanic or Latino Descent American Indian or Alaska Native Asian
Black or African American Native Hawaiian or Other Pacific Islander White Other
Hobbies/Interests/Community Involvement:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
What are your goals and anticipated benefits of being part of this program?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
I prefer to mentor a student who has/is pursuing a degree(s) in: (Check all that apply)
General Business Management Management Information Systems
Accounting Finance Economics Global Economics
Marketing Global Marketing Sales Management Supply Chain Logistics
MBA MACC
Interest in being an entrepreneur
2 of 3
UWF College of Business | 11000 University Parkway | Pensacola, FL 32514
Hospitality
The following person has recommended me for this program: (Optional)
Name: ____________________________________________________________________________________________________________
Title: ______________________________________________________________________________________________________________
Company: ________________________________________________________________________________________________________
Email Address: __________________________________________________________________________________________________
Phone: ____________________________________________________________________________________________________________
By checking this box and submitting this application you acknowledge that the information is true
and accurate to the best of your knowledge.
Volunteer workers shall be covered by Worker' Compensation and by Florida State Liability
Protection in accordance with the provisions of Florida Statute 768.28.
By signing below, volunteer acknowledges receipt and understanding of the University policy on
fraudulent or other wrongful acts and receipt of the policy concerning the University as a
Drug-free workplace.
Thank you for applying. You will be contacted by the UWF Executive Mentor
Program soon.
Signature: _________________________________________________________________ Date: ___________________________
Return Application: Building 76A/224 | Fax 850.474.2342 | executivementor@uwf.edu
3 of 3
UWF College of Business | 11000 University Parkway | Pensacola, FL 32514
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I authorize the University of West Florida, acting for and on behalf
of the University of West Florida Board of Trustees (“University”)
and those acting pursuant to its authority to:
record my likeness and/or voice on a video, audio, photographic, digital,
electronic or any other medium;
use my name and biographical material in connection with such recordings; and
use, reproduce, exhibit, and/or distribute my name, biographical material, and
such recordings in any medium (e.g., print publications, video, internet, etc.) for
a variety of promotional, advertising, educational, and/or other lawful purposes.
I agree to release the University from all liability related to the recordings and waive
any claims or rights of compensation or ownership regarding such uses, and agree
and understand that all such recordings shall remain the property of the University.
❑ Student ❑ Faculty ❑ Sta ❑ Other
Name of Participant
(Please print)
Signature of Participant Date
(If 18 or older)
IF UNDER 18:
Legal Guardian Name
(Please print)
Legal Guardian Signature Phone number
Email
OFFICE USE ONLY:
Project/Intended Use
Filed By
Photo/Video Release Form
(i)
(ii)
(iii)
Institutional Communications | brand.uwf.edu | uwf.edu/institutionalcommunications
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EMP Mentor Application Fillable (University of West Florida)

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Completed 20 July 2020

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