ACMS Diversity Mentorship Program - Mentee Application Question Title * 1. Name Question Title * 2. Residency Program/Institution Question Title * 3. Address Question Title * 4. Address 2 Question Title * 5. City/Town Question Title * 6. State/Province Question Title * 7. ZIP/Postal Code Question Title * 8. Email Address Question Title * 9. Phone Number Question Title * 10. Residency Completion Year or Anticipated Completion Year Question Title * 11. Does your dermatology program have a Mohs surgeon who isfellowship-trained? Yes No Question Title * 12. Do you identify as underrepresented in medicine (URM)? Yes No Question Title * 13. What is your race/ethnicity? 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) Question Title * 14. What is your gender? Male (including transgender men) Female (including transgender female) Prefer Not to Say Prefer to self-describe (non-binary, gender-fluid, please specify): Question Title * 15. Please select areas of mentorship interest (select all that apply). General career guidance Interview coaching Leadership Applications for micrographic surgery and dermatologic oncology fellowship(including personal statement) Networking Research and Grants Shadowing Innovation Question Title * 16. Please describe your interest in the ACMS Diversity MentorshipProgram (Max 500 words). Question Title * 17. Please attach your Curriculum Vitae PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please attach your Curriculum Vitae Question Title * 18. For current residents: I attest that I am in good standing in anACGME-approved dermatology residency program and able to fullyparticipate in this mentorship program. I attest No (please specify) Done