Bronco Stampede Membership Application

Contact Information

Name

First Name

Initial (optional)

Last Name

Date of Birth

Bronco ID Number

Home Address

Address Line 1

Address Line 2

City

State

ZIP Code

Current Residence Address

Address Line 1

Address Line 2

City

State

ZIP Code

Home Phone

Cell Phone

Best times to reach you by phone:

Emergency Contact

First Name

Last Name

Emergency Contact Phone

Emergency Contact Relationship

References

Please ask any non-relative (for example, professor, staff, friend, employer, coach, advisor). References will be sent a form through their email. Make sure you use the correct email address for each reference.

1. Name

1. Title

1. Email

1. Phone

2. Name

2. Title

2. Email

2. Phone

Honors Received

Please list all honors or awards received:

Leadership Positions

List all leadership positions held and list all clubs and / or council affiliations:

Volunteer Activities

List all community and / or volunteer activities:

Availability

You must be available to participate and represent Cal Poly Pomona at least 40 hours per quarter. This requires participation at Alumni Affairs events: National Development Council, Southern Cal. Tasting and Wine and other events throughout the year. In addition, BroncoStampede Ambassadors must be available to commute to various high school campuses and community colleges in the area in order to deliver presentations to prospective students and their families. Also, BroncoStampede students must maintain a 3.00 GPA every quarter. Lastly, all BroncoStampede Ambassadors have to attend monthly meetings on campus.

I certify that all statements on this application are true and complete to the best of my knowledge and belief. If the information provided is found false you will be removed from consideration. If selected to be a BroncoStampede Ambassador, I hereby state that I will be able to participate at least 40 hours per quarter. Finally, I agree to promote Cal Poly Pomona and increase awareness of the benefits of the Alumni Association.

Questions

Please answer the following questions in complete sentences, using no more than one page (double-spaced) per questions.

1. How have you practiced Cal Poly Pomona’s philosophy “Learn By Doing” in your own life?

2. What motivates you to succeed?

3. Why do you want to become a BroncoStampede Ambassador?

4. It’s often said, “you live, you learn.” What has been your biggest obstacle and what did you learn from that experience?

Signature

I certify that all statements on this application are true and complete to the best of my knowledge and belief.

If the information provided is found false you will be removed from consideration. If selected to be a BroncoStampede Ambassador, I hereby state that I will be able to participate at least 40 hours per quarter. Finally, I agree to promote Cal Poly Pomona and increase awareness of the benefits of the Alumni Association.

Signature

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If you cannot use the signature area above, be type your full name and email below

Date/Time

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Progress

Contact Information

Academic History

References

Honors Received

Leadership Positions

Volunteer Activities

Availability

Questions

Signature