P.O. Box 541429 Flushing, NY (718) 460-3801 Ext.11, (917) 885-3584 Mentor Application Unni Hyung Mentoring Program – Date:_________________ General Information Full Name _____________________ M ____ Last _______________________ Address City, ST, ZIP Code Primary Phone # ( ) ________ - __________ Alt. Phone # ( ) ________ - __________ E-Mail Address Birth Date MM/DD/Year ________/________/____________ Birthplace (Country) # of years in the U.S. Ethnicity (please specify) Spoken languages besides English Internet Brochure Police Precinct Friend / Family TV Other Organization How did you hear about the Unni-Hyung Program? Event Newspaper National Mentoring Partnership (please specify) _______________________________________ Employment Are you Currently Yes No Employed?
P.O. Box 541429 Flushing, NY (718) 460-3801 Ext.11, (917) 885-3584 Mentor Application Unni – Hyung Mentoring Program Date:_________________ General Information Full Name _____________________ M ____ Last _______________________ Address City, ST, ZIP Code Primary Phone # ( ) ________ - __________ Alt. Phone # ( ) ________ - __________ E-Mail Address Birth Date MM/DD/Year ________/________/____________ Birthplace (Country) # of years in the U.S. Ethnicity (please specify) Spoken languages besides English How did you hear about the Unni-Hyung Program? Internet Brochure Police Precinct Friend / Family TV Other Organization Event Newspaper National Mentoring Partnership (please specify) _______________________________________ Employment Are you Currently Employed? Yes No
Mentor-Application.docx