Project Move Mentor Application

Legal Name

First M.I. Last

Prefer to Use Birth Date

Age Sex Male Female

Race

Social Security Number

Current Address

Address City State Zip Code

Home Phone Cell Phone

Permanent Address (LEAVE BLANK IF SAME AS ABOVE)

Address City State Zip Code

E-Mail (ADDRESS YOU PREFER PROJECT MOVE TO USE) Work Address Home Address

Please list all people currently residing in your home other than you.

First Name	Last Name	Relationship to Applicant	Age

What Changes in your family, vocation or address do you anticipate in the next year?

Have you ever applied to become a mentor with Project MOVE or any other organization of project before? Yes No

If yes, where and when?

Are you currently a student? Yes No School Attending

Employment Information

Employer Occupation

Address City State Zip Code

Work Phone Ext.

May we call you at work? Yes No Date of Hire

What are you work days and work hours?
If unemployed, what is your means of support?

Reference Information

List the names, addresses and daytime phone numbers of five references. Include present or former work supervisor/employer (if not applicable, please list an additonal reference in that box) and only one relative (other than spouse). The remaining three references should be friends who have known you two years or longer. If you are new to the area, you may use people outside the area. Your references will receive a cover letter and reference form to complete and return.

***Please include e-mail address if reference would be comfortable with receiving referene form as MIcrosoft Word attachment. Upon completion the reference form could be returned by mail or saved as a new document (i.e. John Smith Reference) and sent as an attachment inserted in a new e-mail message.

1. Supervisor's Name (present or former)	Relationship	How long known	Daytime Phone

Address	City	State	Zip Code

E-Mail Address

2. Relative's Name	Relationship	How long known	Daytime Phone

Address	City	State	Zip Code

E-Mail Address

3. Name (not a relative)	Relationship	How long known	Daytime Phone

Address	City	State	Zip Code

E-Mail Address

4. Name (not a relative)	Relationship	How long known	Daytime Phone

Address	City	State	Zip Code

E-Mail Address

5. Name (not a relative)	Relationship	How long known	Daytime Phone

Address	City	State	Zip Code

E-Mail Address

PROJECT MOVE MENTOR AGREEMENT

As a part of the screening process, I understand that additonal personal information will be gathered from me by the agency. I also understand that a Match Coordinator must approve my application before I will become a Mentor.

I understand and agree that I am under no obligation to perform the volunteer services herein applied for, nor is the agency obligated to assign or actively seek to assign me a Participant. However, once matched, I will take an active part and agree to visit with my matched Participant two to four times per month for at least one year, or as agreed to with the Match Coordinator. To the best of my knowledge, the preceding information I have completed on this form is true and factual. I underand these records ar subject to the Project MOVE Confidentiality Policy.

YES, I UNDERSTAND AND AGREE