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* 1. What is your name?

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* 2. Year of graduation from specialist training

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* 3. Would you like to register your interest in being a Mentor or Mentee?

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* 4. What is your current location (city, state, country)?

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* 5. Please rank your 5 strongest areas of interest (Mentees) or expertise (Mentors).

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* 6. How do you envisage communicating with your Mentor/Mentee?

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* 7. As a Mentee, please describe in more detail the area of professional development that you would MOST like to explore in a Mentor/Mentee relationship?

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* 8. As a Mentor, please provide more detail on your strongest area(s) of expertise that you feel would benefit a Mentee in the program?

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* 9. Please list any preferences such as gender, age, number of years since graduation, geographical location (excluding your own location) etc that you would like taken into consideration when we are matching Mentor/Mentee pairs

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* 10. Do you have any other comments or suggestions to assist the committee with pairing up of a suitable Mentor/Mentee coupling?

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