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Mentee Questionnaire

* 1. Demographic information:

2. Specialty:

3. Practice setting:

* 4. Geographic location:

5. Percentage of PAG in your practice:

6. Surgical volume:

7. Interest in research:

8. Desire to host international member:

9. Interest in academic advancement:

10. Interest in research:

11. List of faculty whom applicant would like as their mentor: (optional)

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