AHNS Mentorship Program – Mentee Application AHNS Mentorship Program – Mentee Application Name(Required) First Middle Last Institution(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Gender(Required) Age(Required) 30-35 36-40 41-45 46-50 51-55 56+ What is your degree?(Required) DO MD PhD MD/PhD Do you have other advanced degrees? If so, please list: Did you complete a Fellowship?(Required) Yes No Where did you complete your Fellowship?(Required) How many years ago did you complete your training?(Required) <5 5-10 11-15 16-25 25+ Specialty Focus (Please pick your Subspecialty focus)(Required) eg: ablative/ recon/ endo/ basic sciencePractice Setting (check all that apply)(Required) Academic Private practice – single physician Private practice – multi-physician Hospital based VA Other Other Practice Setting(Required) If Academic, what is your title? Fellow Instructor Assistant Professor Associate Professor Full Professor/Surgeon Select your top 3 areas for mentorship from the following list:(Required) Career development (eg. Promotion, contract negotiation) Research Goals Practice development Work and Outside-of-Work integration Transition to Practice Leadership Development Education of residents and or medical students Other Work and Outside-of-Work integration – Please specify if you are married, single, your race, if you have a young family, want to start a family, etc. so that we can match you to an appropriate mentee(Required) Other Mentorship Area(Required) Please rank the matching factors that are most important to you with top ranking being most important. (please use the mouse to drag the items to order of most important to least)Sub-SpecialtyMentorship AreaGender of MentorMentor/Mentee matches are made weighing multiple factors, and not all requests can be accommodated. What is the most important quality of a good mentor? (Please pick only one)(Required) Approachable Well known in own field Well published Has own laboratory Compassionate Prepared Enthusiastic Willingness to sponsor my future efforts What is the most important quality of a good mentee? (Please pick only one)(Required) Motivation to succeed Time management Willingness to learn Respectful Clear communication Positive attitude Organized What time availability would you prefer from a mentor?(Required) Monthly meetings Quarterly meetings Personal Statement – Include a brief paragraph outlining why you wish to be a mentor and what you hope to gain from participating in this program. (500 words maximum)(Required)Please upload your CV(Required)Accepted file types: pdf, doc, docx, Max. file size: 100 MB.NameThis field is for validation purposes and should be left unchanged. Δ Share:FacebookTwitterLinkedIn