Student Executive Mentor Program Application

Email

This field is for validation purposes and should be left unchanged.

By checking this box, you acknowledge that you qualify for participation in the Executive Mentor Program.*

Yes, I am currently enrolled as a student in a School of Business & Leadership program and have completed at least one School of Business & Leadership course.

Name*

First Middle Last Suffix

Sex*

Male
Female

Student ID #*

Current Degree Program*

(check all that apply)

MA Org. Leadership
MS Accounting
MS Business Analytics
MBA
DBA
DSL
PhD Business
PhD Org. Leadership

Current Cumulative GPA*

Please enter a number from 0.0 to 4.0.

Expected Graduation*

(month and year)

I’m a…

(check all that apply)

International Student
Student with Disabilities
First Generation Student
Active Military or Veteran

Resume Upload*

Please upload your resume as a Word document (.doc or .docx) or PDF here.

Accepted file types: doc, docx, pdf, Max. file size: 20 MB.

Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Mobile Phone*

Home Phone*

Regent Student Email Address*

Preferred Email Address*

I prefer a mentor with the following specialization*

We will try to accommodate your preference but may not be able to do so given the pool of mentors.
(check all that apply)

Please specify*

Personal Summary*

Be honest and give your future mentor a view of who you are, and how your life experiences so far have shaped you.

Career Plans and Aspirations*

Honestly answer the question, “What do you want to be when you grow up?”

Hobbies/Interests*

Do you play an instrument? Are you skilled in a specific sport or have a favorite team? Tell your potential mentor what you do for fun.

Christian Testimony & Denominational Affiliation*

Share your spiritual journey and current denominational/church affiliation.

Why I want an Executive Mentor*

What are some of the things you would want your mentor to help you with? Identify what you expect of your mentor, from a specific industry to the goals for your career most in need of help.

Executive Mentor Preference*

No Preference
Female
Male

How did you hear about this program?*

Faculty
Staff
Friend
Admissions
Advising
Advertisement
Canvas Announcement
Other (please explain)

Please explain*

The following person has recommended me for this program:

Referrer Name

First Last

Referrer Title

Referrer Company

Referrer Email

Referrer Phone

By checking this box and submitting this application, you acknowledge that the information is true and accurate to the best of your knowledge.*

Yes, the information on this application is true and accurate to the best of my knowledge.

Authorization for Release of Student Information*

Yes, I authorize 91�� to release information from this application and the resume I submit to potential mentors to facilitate the matching process with a business executive. The above information may be released with my full consent.

Signature*

Date*

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Student Executive Mentor Program Application

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