Please include the following and mail your complete application to Project Anna, P.O. Box 541, Greenville, NC 27835:

· A transcript (from your present school, college or university)

· Two reference letters

· A one page, typed, double-spaced essay on “Two Things That Would Enhance My Life.”

Please type or print legibly and supply all requested information. Please list your name, as you want it to appear on your name badge.

Last Name First Name M.I.

Mailing Address Apt. /Suite

City State Zip/Postal Code

Area Code/Daytime Phone Area Code/Evening Phone

Area Code/Cellular Phone or Pager Email address

Participant’s Age Parent/Guardian Signature (if under 18)

Please answer the following questions:

Are you presently employed? ____ Yes ___ No

Are you a member of a church? ___ Yes ___No, if yes, please list church name and pastor. ___________________________________________

Do you have any health concerns? ___Yes ___No, if yes please list below.

____________________________________________________________________

Have you ever been convicted of a criminal offence? ___ Yes ___ No, if yes, Do you presently have a Court counselor or Probation Officer?

*Having a past criminal record will not disqualify you from this program.

All information is true to the best of my knowledge and I agree to interview in order to receive services from this Mentor program.

____________________________ _______________

Signature Date