Early Career Research Mentoring Program

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* 1. First Name:

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* 2. Last Name:

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* 3. Credentials:

MD

DO

PhD

Other (please specify)

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* 4. Organization/Institution:

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* 5. Email:

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* 6. In what year did you graduate from Fellowship?

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* 7. Name of Fellowship Program:

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* 8. Do you plan to attend the AUGS/IUGA Scientific Meeting June 14-18, 2022? (This will not impact your ability to participate but will aid the committee in planning)

Yes - Attending in person

Yes - Attending virtually

No - Not planning to attend

Unsure

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* 9. Are you volunteering to serve as a mentor or applying to participate as a mentee?

Mentor

Mentee