Part I: Student Information

Name:

Email:

Home Phone #:

Cell Phone #:

Local Address:

Year (Fr., So., Fr., Sr.):

Date of Birth (MM/DD/YY):

Major/Minors:

Hometown:

Extracurricular Activities and Involvement:

Hobbies & Interests (Check ALL that apply):

Part II: Short Answer

What are you looking for in a mentor? What role would you like your mentor to play in your transition to Purdue University North Central?