In Reach Maverick Mentor Program
In Reach Maverick Mentor Program
Mentee Nomination Form
Please provide the following information for the student you wish to nominate.
Nominee's Name:
Nominee's Name:
*
First
Last
Nominee's Major:
*
First option
Nominee's Year in College:
*
Freshman
Sophomore
Junior
Senior
Grad Student
Nominee's Address:
Nominee's Address:
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
-------
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Nominee's Phone Number - Day:
Nominee's Phone Number - Day:
*
-
###
-
###
####
Nominee's Phone Number - Evening:
Nominee's Phone Number - Evening:
*
-
###
-
###
####
Nominee's Email Address:
*
Nominee's Race/Ethnicity:
For the nominator to complete (you can self nominate).
Nominator's Name:
Nominator's Name:
*
First
Last
Nominator's Title and Department (if applicable):
Nominator's Phone Number:
Nominator's Phone Number:
*
-
###
-
###
####
Nominator's Email Address:
*
Nominator's Relationship or Affiliation with Nominee:
*
Rate the following characteristics of the nominee from 1 (weak) to 5 (strong).
Reliability Rating:
*
1 weak
2
3 moderate
4
5 strong
Reliability Comments:
Dedication Rating:
*
1 weak
2
3 moderate
4
5 strong
Dedication Comments:
Teamwork Rating:
*
1 weak
2
3 moderate
4
5 strong
Teamwork Comments:
Leadership Rating:
*
1 weak
2
3 moderate
4
5 strong
Leadership Comments:
Initiative Rating:
*
1 weak
2
3 moderate
4
5 strong
Initiative Comments:
Motivation Rating:
*
1 weak
2
3 moderate
4
5 strong
Motivation Comments:
Academic Promise Rating:
*
1 weak
2
3 moderate
4
5 strong
Academic Promise Comments:
Describe the nominee in 3 words.
Word 1:
Word 2:
Word 3:
Answer the following questions about the nominee.
What is an area of growth that you would like see for the nominee in the future?
What academic issues do you feel the nominee needs assistance with?
What tools do you feel the nominee needs assistance with in order to be successful at UT Arlington?
What are the major reasons you feel the nominee would be a good candidate for the In Reach Maverick Mentor Program?
Is the nominee currently involved in another mentor program? If yes, please provide the name of the program.
Thank you for your nomination.
Maverick Connect