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ACMS Diversity Mentorship Program - Mentor Application 2026
1.
Name
2.
Practice Name
3.
Practice Type/Setting
4.
Address
5.
Address 2
6.
City/Town
7.
State/Province
8.
ZIP/Postal Code
9.
Email Address
10.
Phone Number
*
11.
What is your race/ethnicity? Applicants of any background are eligible
to apply.
(Required.)
White
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Multiple Races
Other (please specify)
*
12.
What is your gender?
(Required.)
Male (including transgender men)
Female (including transgender female)
Prefer Not to Say
Prefer to self-describe (non-binary, gender-fluid, please specify):
*
13.
Does your practice include training of fellows-in-training as part of an
ACGME-approved Micrographic Surgery and Dermatologic Oncology
fellowship?
Yes
(Required.)
Yes
No
*
14.
Please indicate areas for which you are willing to provide mentorship
to a mentee (select all that apply).
(Required.)
General career guidance
Interview coaching
Leadership
Applications for micrographic surgery and dermatologic oncology fellowship
(including personal statement)
Networking
In-person research opportunities
Remote research opportunities
Grant-writing
Shadowing opportunities
Innovation
15.
Please briefly describe your interest in serving as a mentor for the ACMS
Diversity Mentorship Program. (Max 250 words).
*
16.
Please attach your Curriculum Vitae
(Required.)
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