SfRBM Mentoring Program: Mentee Application

1. Contact Information

25% of survey complete.

Thank you for taking the time to complete the Mentee Application online and becoming a part of this important program. We look forward to working with you and matching you with one of the Mentors.

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* 1. Please provide your contact information:

First Name:

Last Name:

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* 2. Contact information continued:

Affiliation/Company:

Address: *

Address 2:

City/Town: *

State: *

ZIP/Postal Code: *

Country: *

Email Address: *

Phone Number: *

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* 3. What is your current position?

Undergraduate Student

Graduate Student (Masters)

Graduate Student (PhD)

Medical Student

Post-doctoral Fellow

Junior Faculty

Other

Other (please specify)

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* 4. How many years have you been in your current position?

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* 5. If in a degree/graduate program, when do you anticipate graduating?

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* 6. What type of organization do you work for? (Select all that apply)

University

Health Science Center

Biotech Company

Government Research Laboratory

Other

Other (please specify)