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* 1. Anticipated setting of your mentorship

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* 2. Anticipated mentorship location:

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* 3. Mentor's affiliation details:

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* 4. Please identify up to 3 potential areas of mentorship/expertise to be offered to interested residents:

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* 5. (optional) Additional details regarding area 1

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* 6. (optional) Additional details regarding area 2 (if applicable)

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* 7. (optional) Additional details regarding area 3 (if applicable)

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* 8. Your contact information to be used by the Preceptorship Program:

Thank you for your interest!  Your information will be reviewed by the Preceptorship Subcommittee. You will be contacted to confirm more details if needed. Otherwise, the information you provided will be shared with resident applicants who request it. 
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