Medical Dermatology Society
2024-2025 Mentorship Program Application

MDS Mentorship Application

Question Title

* 1. Applicant Information

First, Last, Degree *

Institution *

City/Town *

State/Province *

ZIP/Postal Code

Country

Email *

Phone *

Question Title

* 2. Check All That Apply

MDS Member

Resident

Fellow

Junior Faculty

Question Title

* 3. Mentor Information

First, Last, Degree *

Institution *

City/Town

State/Province

ZIP/Postal Code

Country

Email *

Phone

Question Title

* 4. Mentorship Information

Mentorship Focus

Potential Mentorship Dates

Question Title

* 5. Have you previously applied to the Medical Dermatology Society Mentorship Program?

Yes: I have previously applied to the MDS Mentorship program

No: I have NOT applied to the MDS Mentorship program in previous years

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* 6. Have you applied to any other Mentorship Program(s)?

Yes: I have applied to other Mentorship program(s)

No: I have NOT applied to any other Mentorship program(s)

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* 7. Letter of Recommendation from Potential Mentor

Mentor's acknowledgment and support of the project. Description of projects and/or experiences the applicant will undertake during the mentorship.

DOCX, DOC, JPG, GIF, JPEG, PDF, PNG file types only.

Choose File

Question Title

* 8. Letter of Recommendation from Department Chair or Program Director

Describing the suitability of the mentorship opportunity for the applicant and how this mentorship will impact the applicants career path

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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Question Title

* 9. Statement of Proposed Applicants Goals and/or Achievements

Describe how this mentorship opportunity help you optain your long term career goals if accepted into the program. Limit the Statements of Proposed Goals to one (1) page.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 10. Applicants Bio-Sketch or Curriculum Vitae

4 page maximum

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

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* 11. Any remarks or comments that you would like to convey to the review committee?

The membership will be notified of the awardees at the
MDS Annual Meeting on Thursday, March 7th in San Diego, California

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