JCEL - Mentor Enrollment Form

Today's Date: 12/2/2008

First Name:
Lst Name:
JC grad year:
Home Address:
City:	State: Zip: -
Home Phone:	( ) -
Home E-mail:

Current Employer:
Position Title:
Business Address:
City:	State: Zip: -
Business Phone:	( ) -
Business Fax:	( ) -
Business E-mail:
Business Website:	http://

Please check your preferred method(s) of mentor contact.
Home Phone	Business Phone	Home Email	Business Email
On Campus Visit	At your place of employment	Other:

Can we include your contact information on the Juniata Career Team electronic database (located on the Juniata College intranet)? Yes No

Do you consider yourself an entrepreneur? Yes No

Have you provided professional services to entrepreneurs (i.e., are you an entrepreneur supporter)? Yes No

Do you have experience with or knowledge of any of the following? Please check all that apply:
Accounting	Business Ethics	Business Legal Structures
Business Plans	Copyrights	Customer Service
Finance	Distribution	Import/Export
Marketing	Manufactoring	Operations
Patents	Payroll	Project Planning Software
RFP’s	Small Business Loans	Supply Chain Management
Trademarks	Venture Capital	Website Design
Other:

What groups of start-up businesses would you prefer to mentor? Please check one or more:
JC Students	JC Faculty and Staff	JC Alumni	Huntingdon Area Residents

Would you be interested in coming to Juniata to do a presentation for a group of entrepreneurs? Yes No

What topic would you like to present?

Please list the name and contact information for any other entrepreneurs or entrepreneur supporters whom we should contact.

Please write a brief narrative describing any experience you have had with your own business start-up (for-profit or not-for-profit) or support you have provided for other business start-ups. Include the nature of the business and your role in the venture.

Feel free to include any additional materials (biographical sketch, business card, marketing materials from your own business, list of publications, etc.).