[ Application for Mentors _ English ]

Dear Candidate,

Through this survey, we are collecting your data to become a WFSA mentor. Applications for this edition will be open from 10 April to 10 May 2024.

Before completing this application form, please note that the minimum duration of this programme will be one year, from the start to the end of the mentoring programme. Please make sure to fill in the application form in your preferred language for mentoring (English, French or Spanish).

If you have any problems completing this survey, please contact us by email: mentorship@wfsahq.org

Thank you for your time and cooperation,

WFSA Secretariat

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* 1. Title

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* 2. First Name

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* 3. Surname

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* 4. Email

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* 5. Telephone (please, add your country code)

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* 6. Date of birth (day/month/year)

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* 7. Gender

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* 8. Nationality

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* 9. Country where you work

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* 10. City and Country of your institution

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* 11. Current working position

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* 12. Current Career Level

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* 13. Year you obtained your medical degree

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* 14. Year in which you obtained your speciality degree in Anaesthesiology

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* 15. Area of specialization in Anaesthesiology

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* 16. Years of experience in your area of specialisation in anaesthesiology

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* 17. Name of the National Society of Anaesthesia you are affiliated to

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* 18. Do you have previous experience as a mentor, and if so, at which institution and on which dates?

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* 19. Briefly describe your strengths as a mentor (maximum 200 words)

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* 20. What are your areas of clinical and academic interest? Clinical, Career development, or Leadership (Please, choose one and add any comment If needed)

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* 21. In case you have chosen the Clinical Area, please choose one of these categories:

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* 22. Please briefly describe your motivation for mentoring at the WFSA (maximum 200 words)

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* 23. Describe at least two goals or accomplishments you would like to achieve as a mentor

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* 24. Languages you speak

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* 25. Languages you write

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* 26. Preferred language(s) of communication

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* 27. Short biography (maximum 200 words)

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* 28. Would you be interested in participating as a speaker in one of the quarterly webinars in English, which will be offered in the WFSA Global Mentoring Programme?

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* 29. Please upload your CV here

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* 30. Please, upload here the Proof of Membership to your National Society of Anaesthesiologists (which must be a Member of the WFSA)

(*** Important: Please note that incorrect documentation might delay your application)

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Choose File

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* 31. I agree to the following points:

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