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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