The Chair Academy : Mentor Selection Form
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Mentor Selection Form
Please fill in the information below. If you have questions concerning the form, please contact the Academy Liaison. After submitting this form, please press the "back" button on your browser toolbar to return to your class web page.

Participant Information

Your Name:
Your College (please spell out the name):

Internal Institutional Mentor

(please enter the information of the mentor you have chosen):
Name: Email:
Title: College:
College Address: City, State, Zip:
Country: Province (if applicable):
Phone #: Fax #:

External Mentor

(please enter the information of your second mentor):
Name: Email:
Title: College:
College Address: City, State, Zip:
Country: Province (if applicable):
Phone #: Fax #:


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Chair Academy 2010 Conference
Call For Proposals
Nominate a Leader
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