NFBTX Mentor Application Form
An application form to become a National Federation of the Blind of Texas Mentor
Name (First, Middle, Last) *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Telephone Number *
Your answer
E-Mail Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Please check the appropriate items below.
Gender *
Required
With which of the following ethnic groups do you most closely identify? *
Required
If you marked "other" for above, please specify here.
Your answer
Employment history (list most recent first)
Employer 1
Current or most recent employer.
Your answer
Title
Your answer
Employment dates:
Your answer
Briefly describe your work.
Your answer
Reason for leaving:
Your answer
Employer 2
Previous employer.
Your answer
Job Title
Your answer
Employment dates
Your answer
Briefly describe your job.
Your answer
Reason for leaving
Your answer
References
Name 1:
Your answer
Phone number:
Your answer
Alternate phone number:
Your answer
Name 2:
Your answer
Phone number
Your answer
Alternate phone number
Your answer
Name 3:
Your answer
Telephone number:
Your answer
Alternate telephone number:
Your answer
What is the cause of your blindness or low vision? (Glaucoma, Retinitis Pigmentosa, ROP, etc.) *
Your answer
What is your visual acuity?
Your answer
Please list your field loss, if any.
Your answer
Please list any additional disability/disabilities (if applicable).
Your answer
Please check your highest educational level, or the highest degree you have obtained: *
Required
Please list the highest degree you have obtained and/or license you hold: *
Your answer
Please check next to the category that most closely identifies your primary occupation/activity: *
Required
If you marked "other" above, please specify here.
Your answer
Please list all organizations with which you are currently affiliated and active. Please be sure to include civic, community, social, etc. *
Your answer
Is there anyone you would recommend as a possible blind or low vision mentor? If so, please provide his or her name and contact information:
Your answer
I agree to follow all mentoring program guidelines and understand that any violation will result in suspension and/or termination of the the mentoring relationship. *
Agreement is required in order to participate in the program. Please initial.
Your answer
I understand that the National Federation of the Blind of Texas Mentoring Program is not obligated to provide a reason for its decision to accept or reject me as a mentor. *
Agreement is required in order to participate in the program. Please initial.
Your answer
I agree to allow the National Federation of the Blind of Texas Mentoring Program to use any photographic image of me taken while participating in the mentoring program. These images may be used in promotional or other related marketing material. *
Agreement is not required in order to participate in the program. Please initial if you agree.
Your answer
By signing below, I attest to the truthfulness of all information listed on this Application and agree to all the above terms and conditions.
Signature *
Type your full name in the space provided. This will serve as a digital signature.
Your answer
Date *
Your answer
Submit
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