Academic Senate Mentor Application

Name*

First Last

Department/School*

Campus Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Years at PCC*

Years at other institutions(s)/Locations*

Academic Title*

Courses Taught*

Hobbies and Interests*

Phone*

Email*

Enter Email Confirm Email

Two PCC References

Reference 1 Name*

First Last

Reference 1 Phone*

Reference 2 Name*

First Last

Reference 2 Phone*

Please check areas of teaching activity that you wish to discuss with a mentee*

Other Technical Skills*

Other Pedagogical Skills*

Other Teaching Activity*

Please check areas of professional activity you feel prepared to discuss with a mentee*

Other Professional Activity*

How would you prefer to communicate with your mentee?*

Name

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