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* 1. Enter full name, address, and cell phone number (answer all questions)

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* 2. Enter your date of birth

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* 3. Place of Employment and length of time employed

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* 4. Emergency contact name, relationship, and phone number

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* 5. 3 Reference Names, time known, phone number (New Mentors ONLY)

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* 6. Agree to meet with your mentee at least once per month, if reasonably possible

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* 7. Do you have a car and a current driver's license? Provide DL number and expiration date here. Email copy of DL and auto insurance policy.

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* 8. Do you give permission for use of any photo of you to be used by F.U.E.L., Inc. for public relations?

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* 9. What are some of the things you want to get from this mentoring program?

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* 10. I hereby confirm that I am an adult over the age of 23 and all information above is accurate and complete. I agree to participate in program activities and promise to provide fingerprint and background check information as required. I also agree to release F.U.E.L., Inc, it's officers, and staff, from all liability arising from any harm or injury incurred  while participating in the program stated above. Please print full name and date.

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