Xcel, Inc. Mentor Registration Completing this form enters you into Xcel, Inc.'s Mentor Pool. By submitting this form, you give us the permission to use the information provided to match you with an appropriate mentee. If you are matched with a mentee, you will receive a Welcome Package and steps to comfiming your participation in the Xcel, Inc. Mentoring Program. If you have any questions about this form, please contact Kristin Wormley or Tricia Brunton.
	Contact Information
	First Name:
	Last Name:
	Employer:
	Position:
	Phone Number (e.g. 8009235462) :
	Extension:
	Email Address:
	State of Residence:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
	Educational Information
	Highest level of education:	High School Some College - Associate Some College - Bachelor Some Graduate School Other
	If other, please explain:
	What is your highest professional degree?
	Year Received:
	Are you currently working toward your next professional degree?	Yes No
	What degree are you working towards?
	Year of expected graduation:
	Please let us know why you chose your area of study and or career path:
	Professional Organization Information
	Are you a member of a Professional Organization?	Yes No
	If Yes, what is the name of the Organization?
	Organization Website (if any)
	Do you currently hold a leadership position within the organization?	Yes No
	If yes, What is your position?
	Please let us know why you joined this professional organization?
	Would you recommend this organization to a student?	Yes No
	Mentor Questionnaire
	Do you have mentoring experience?	Yes No
	If yes, please let us know if you received formal training and give a brief description of your experience(s):
	If no, please let us know if you are interested in receiving formal training?	Yes No
	Briefly explain why you are interested in becoming an Xcel Mentor:
	Briefly describe the qualities and attributes you have as an individual and professional to offer to our members:
	Breifly describe what your expectations are of Xcel's Mentoring Program and Your Xcel Mentee:
	Matching Process Questionnaire
	Select a area of study that you would like your mentee to be in?	Arts and Sciences Business Administration Criminal Justice Computer and Information Sciences Engineering Health Sciences Law Other
	If Other, what is the area of study that you would like your mentee to be in?
	Below, rank the first three majors that you would like to mentor in.
	First Choice:	Accounting African-American Studies American Sign Language Animation Anthropology Applied Physics Architecture Art Athletic Training Audiology Behavioral Neuroscience Biochemistry Biology Biomedical Physics Business Administration Cardiopulmonary and Exercise Sciences Chemical Engineering Chemistry Cinema Studies Civil and Environmental Engineering Clinical Exercise Physiology Communication Studies Comparative Politics Computer Engineering Computer Engineering Technology Computer Science Corrections Criminal Justice Criminology Economics Electrical Engineering Electrical Engineering Technology English Entrepreneurship Environmental Geology Environmental Studies Exercise Physiology Finance French Geology Graphic Design Health Science History Human Resources Management Human Services Industrial Engineering Information Science International Affairs International Business International Relations Journalism Juvenile Justice Law and Legal Issues Legal Studies Linguistics Management Management Information Systems Marine Biology Marketing Mathematics Mechanical Engineering Mechanical Engineering Technology Media Studies Medical Laboratory Science Multimedia Studies Music Music Industry Music Literature Music Literature Music Performance Music Technology Nursing Organizational Communication Other Pathways Pharmacy Philosophy Photography Physical Therapy Physics Policing Political Science Psychology Public Administration Public Relations Respiratory Therapy Security Sociology Spanish Speech-Language Pathology Supply Chain Management Theatre Theatre Performance Ujima Scholars Women's Studies
	If Other, what major is your first choice?
	Second Choice:	Accounting African-American Studies American Sign Language Animation Anthropology Applied Physics Architecture Art Athletic Training Audiology Behavioral Neuroscience Biochemistry Biology Biomedical Physics Business Administration Cardiopulmonary and Exercise Sciences Chemical Engineering Chemistry Cinema Studies Civil and Environmental Engineering Clinical Exercise Physiology Communication Studies Comparative Politics Computer Engineering Computer Engineering Technology Computer Science Corrections Criminal Justice Criminology Economics Electrical Engineering Electrical Engineering Technology English Entrepreneurship Environmental Geology Environmental Studies Exercise Physiology Finance French Geology Graphic Design Health Science History Human Resources Management Human Services Industrial Engineering Information Science International Affairs International Business International Relations Journalism Juvenile Justice Law and Legal Issues Legal Studies Linguistics Management Management Information Systems Marine Biology Marketing Mathematics Mechanical Engineering Mechanical Engineering Technology Media Studies Medical Laboratory Science Multimedia Studies Music Music Industry Music Literature Music Literature Music Performance Music Technology Nursing Organizational Communication Other Pathways Pharmacy Philosophy Photography Physical Therapy Physics Policing Political Science Psychology Public Administration Public Relations Respiratory Therapy Security Sociology Spanish Speech-Language Pathology Supply Chain Management Theatre Theatre Performance Ujima Scholars Women's Studies
	If Other, what major is your second choice?
	Third Choice:	Accounting African-American Studies American Sign Language Animation Anthropology Applied Physics Architecture Art Athletic Training Audiology Behavioral Neuroscience Biochemistry Biology Biomedical Physics Business Administration Cardiopulmonary and Exercise Sciences Chemical Engineering Chemistry Cinema Studies Civil and Environmental Engineering Clinical Exercise Physiology Communication Studies Comparative Politics Computer Engineering Computer Engineering Technology Computer Science Corrections Criminal Justice Criminology Economics Electrical Engineering Electrical Engineering Technology English Entrepreneurship Environmental Geology Environmental Studies Exercise Physiology Finance French Geology Graphic Design Health Science History Human Resources Management Human Services Industrial Engineering Information Science International Affairs International Business International Relations Journalism Juvenile Justice Law and Legal Issues Legal Studies Linguistics Management Management Information Systems Marine Biology Marketing Mathematics Mechanical Engineering Mechanical Engineering Technology Media Studies Medical Laboratory Science Multimedia Studies Music Music Industry Music Literature Music Literature Music Performance Music Technology Nursing Organizational Communication Other Pathways Pharmacy Philosophy Photography Physical Therapy Physics Policing Political Science Psychology Public Administration Public Relations Respiratory Therapy Security Sociology Spanish Speech-Language Pathology Supply Chain Management Theatre Theatre Performance Ujima Scholars Women's Studies
	If Other, what major is your third choice?
	Select the level(s) of study that you would like your mentee to be in:	1st Year student 2nd Year student 3rd Year student 4th Year student 5th Year student (Five Year Institutions) No Preference
	Which 2010 Mentoring Rotation would you like to register for?	March to September June to December September to March, 2011
	How many rotations would you like to be involved in Xcel, Inc.'s Mentoring Program?	One Rotation Two Rotations Three Rotations Four Rotations Five or more Rotations Unsure
	If Unsure, please tell us what circumstances limit your decision:
	Mentor Reference(s)
	In an effort to maintain the safety of  Xcel, Inc. members, please list at least one individual that can verify your identity.
	Reference One
	Full Name:
	Phone Number (e.g. 8009235462) :
	Type of Relationship?	Relative Friend Co-Worker Other
	Length of Relationship?	1-5 years 6-10 years 11-15 years 16 + years
	Reference Two
	Full Name:
	Phone Number (e.g. 8009235462) :
	Type of Relationship?	Relative Friend Co-Worker Other
	Length of Relationship?	1-5 years 6-10 years 11-15 years 16 + years
	Additional Information
	Are you interested in being a guest speaker or panelist at one of our organizational or student chapter events?	Yes No
	Are you or your employer/organization willing to support Xcel, Inc. by making contributions of time, donations and or other resources?	Yes No
	If you contacted by an Xcel, Inc. Board or Student Chapter Member, please indicate which member you corresponded with:	Kristin Wormley Makeda Keegan Neakai Lewis Taleya Hamilton Tricia Brunton Olympia Valentine Rashmi Iyengar NU Xcel Mentoring Coordinator
	If you have any questions, please use the space provided.
	Would you like a copy of your Mentor Request Form emailed to you?	Yes No
	Thank You for Registering.