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Become a Mentor
Mentor Application
To view a job description: Peer Mentor Job Description
Also available: Word file
Name :
(Last, First, Full Middle Name)
Are you planning to serve as :
(please circle one)  
a student, peer mentor
a faculty or staff mentor
Employee or Student ID number (10 digit PeopleSoft)
Campus Address :
Campus or Cell Phone Number :
Email Address:
Emergency Contact Information :
Person to Contact Phone

Have you participated as a FASE or OSM Mentor in the past? Yes No
If yes, when?

What do you hope to accomplish as an OMSLD Mentor?

What are areas of professional interest to you?

What are areas of personal interest to you?

What are two of the greatest challenges college students face today? How might you be able to assist a student in working through those challenges?

Please type your name here Date

Office of the Vice President for Diversity, Equity and Multicultural Affairs
Indiana University, Bloomington

Office of Mentoring Services and Leadership Development
A unit of the Office for Diversity, Equity, and Multicultural Affairs
Eigenmann Hall South Room 619
Bloomington, Indiana 47406-7511, Tell: 812.855.3540, Fax: 812. 812-856-0445
Last updated: January 21, 2011 | Comments: smithpd@indiana.edu
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