Name * Email * Alternate Email Phone Alternate Phone Current Employer Employment History (List post-BS employers and job titles) Explain why you wish to participate in the Mentorship Program Elective Focus Area(s) Qualified to Mentor (check all that apply) Biochemical Engineering Business Chemical Process Engineering Energy and Environment Pharmaceuticals Polymers Pre-Medicine Sustainability Other (Explain below) Elective Focus Area Other Details Indicate Chemical Engineering activities of interest (check all that apply) Mentor Guest lecturer in courses Speaker in Professional Seminar Professional Advisory Board Membership Other (Explain below) Chemical Engineering Other Activities of Interest Details Communication Preference (check all that apply) E-mail Phone Text Message In Person Approval * I give my permission to forward my email address to Tom Marriott, an alumnus of the Chemical Engineering Program at the University of Iowa, who will be in charge of the mentoring program.