Jr Moxxie Mentee Application

Applications for the Fall 2019 / Spring 2020 Program are due by April 30.  
Student applicants MUST be available on certain Fridays to attend two field trips each semester.  Fall field trips will be listed by the end of Spring semester.

Personal Info

First Name:*
Last Name:*
Personal Email Address:*
School Email Address:*
Mobile Phone:*
Date of Birth:*
College Name:*
Graduation Month:*
Graduation Year:*
Home Address:*
Home City:*
Home State:*
Home ZIP Code:*
School Address:*
School City:*
School State:*
School ZIP Code:*

General Info

How did you hear about Jr Moxxie?

If other, please specify

Why do you want to join Jr Moxxie?

If other, please specify

Other than school, what are you involved in?

If other, please specify

Academic Info

College Major:*
College Minor:*
Outside of your major/minor fields, what academic subjects or industries are you interested in?*


Full and partial scholarships may be available. Students receiving scholarships MUST fulfill all program requirements or may be asked to reimburse all or part of their scholarship money. If applying for a full or partial scholarship, please check the box below:

Additional Comments

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