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* 1. Demographic Information

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* 2. GAHE Membership Level

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* 3. Please list your job title and department.

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* 4. Please enter your education history.

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* 5. In what area of healthcare do you currently work? If you work in more than one area, please select your "main" field.

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* 6. In what area(s) of healthcare do you have prior experience? (Check all that apply)

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* 7. Please indicate your years of relevant experience.

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* 8. Do you have a preference in what area your mentee works? If so, please specify which area(s).

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* 9. Do you have any other special requests or preferences in being matched with a mentee? Anything else you would like us to know?

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