* 1. Last Name

* 2. First Name

* 3. Gender

* 4. Ethnicity:

* 5. Email address

* 6. City

* 7. State

* 8. Region

* 11. Employer and Title

* 12. What are the skills (networking, research, teaching), expertise, or other pertinent topics (non-academic careers, industries, family, work/life balance, etc.) aboutwhich you, as a mentor, feel most strongly suited to provide guidance? Please describe briefly how you wish to be of service to students.

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