Student Application

Partners for Success

If you wish to participate in Partners for Success, please complete this form with a written statement of interest.

Last Name:
First Name:
Student Identification Number:
Mailing Address (line 1):
Mailing Address (line 2):
Phone:
E-mail Address:
Major:
Class Level:	Freshman Sophomore Junior Senior
Gender:	Female Male

Does your mother or father have a bachelor's degree?

Yes

Do you have a gender preference for a mentor?

Female

Male

No preference

How did you learn about the Partners for Success program?

Please write a statement of interest explaining why you would like to participate in Partners for Success.