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* 1. Your Name

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* 2. Preferred email address:

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* 3. Preferred phone number:

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* 4. What school are you currently attending?

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* 5. When are you planning to apply for a Dietetic Internship Program?

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* 6. Please provide a brief description of your work/career history.

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* 7. What are your career goals or dreams?

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* 8. What are you hoping to gain from this mentor program? 

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* 9. How would you rank your intern mentor preference?
If you do not have a preference, rank "NO MENTOR PREFERENCE" as your #1 choice. You can also indicate if there is a mentor with whom you do not want to be matched. Your response to this question will remain anonymous to the mentors. While preferences will be considered when possible, your mentor preference cannot be guaranteed.

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* 10. Explanation of mentor preference(s) (response is optional)

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* 11. What days and times of the week work best for meetings with your mentor?

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