College of Engineering

CBE Mentor Application

Name

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.