NAME: _______________________________________________________________

Organization/Affiliate (if any) ____________Mentor DeKalb_____________________

Mailing Address ________________________________________________________

City _______________________ State __________ Zip Code ________

Phone (___________)____________________ Fax (_________)______________

E-mail Address _________________________________________________________

County or Counties of Interest : ____________________________________________

For Background Check Purposes Only: Date of Birth ____________ Gender ____ Race (optional) ____

Social Security Number : ________________________(optional)

How would you like for contact to be established?

 I would like for mentoring organization in my area to contact me directly regarding their programs and my desire to be a mentor.

 I prefer to utilize the list of available mentoring organizations in my area provided by MENTOR ALABAMA to initiate contact with the mentoring organizations myself.

I understand MENTOR ALABAMA will conduct criminal background checks on prospective mentors for the Attorney General's Mentoring Initiative. I consent to a criminal background check for these purposes. I also understand that background checks are conducted to fight crime through appropriate mentor/mentee contact.

PLEASE SIGN HERE: _______________________________________

PLEASE RETURN THIS FORM TO:
MENTOR ALABAMA - c/o Attorney General Bill Pryor - 11South Union Street - Montgomery, Alabama 36130
FAX: (334) 242-7458
TOLL-FREE ALABAMA HOTLINE: 1-888-356-2400