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ACMS Diversity Mentorship Program - Mentee Application 2026
1.
Name
2.
Residency Program/Institution
3.
Address
4.
Address 2
5.
City/Town
6.
State/Province
7.
ZIP/Postal Code
8.
Email Address
9.
Phone Number
*
10.
Residency Completion Year or Anticipated Completion Year
(Required.)
*
11.
Does your dermatology program have a Mohs surgeon who is
fellowship-trained?
(Required.)
Yes
No
*
12.
Do you identify as underrepresented in medicine (URM)?
(Required.)
Yes
No
*
13.
What is your race/ethnicity?
(Required.)
White
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Multiple Races
Other (please specify)
*
14.
What is your gender?
(Required.)
Male (including transgender men)
Female (including transgender female)
Prefer Not to Say
Prefer to self-describe (non-binary, gender-fluid, please specify):
*
15.
Please select areas of mentorship interest (select all that apply).
(Required.)
General career guidance
Interview coaching
Leadership
Applications for micrographic surgery and dermatologic oncology fellowship
(including personal statement)
Networking
Research and Grants
Shadowing
Innovation
*
16.
Please describe your interest in the ACMS Diversity Mentorship
Program (Max 500 words).
(Required.)
*
17.
Please attach your Curriculum Vitae
(Required.)
Choose File
No file chosen
*
18.
For current residents: I attest that I am in good standing in an
ACGME-approved dermatology residency program and able to fully
participate in this mentorship program.
(Required.)
I attest
No (please specify)