TEXAS A&M UNIVERSITY-TEXARKANA
Teacher Preparation Program
(903) 223-3044

Mentor Teacher Information Form

Mentor Teacher: Please complete all blanks below. This information is required for contract and stipend.

Intern's Name
     
  Intern's Name:      
     

Employing District Information
     
  Employing District:      
  Campus:      
     

Mentor Teacher Information
     
  Mentor Teacher's Name:      
  Social Security Number:    
(required for payment purposes)    
 
  Home Address:      
  City:      
  State:      
  Zip Code:      
  Home Phone Number:      
  Email Address:      
     
 

State law requires that you be informed of the following: (1) you are entitled to request to be informed about the information about yourself collected by use of this form (with a few exceptions as provided by law); (2) you are entitled to receive and review that information; and (3) you are entitled to have the information corrected at no charge to you. For more information see our Privacy Statement.