* 1. Are you interested in being a Mentee?

* 2. Are you interested in being a Mentor?

* 3. If you are interested in being a Mentee, how many years ago did you complete:

* 4. Please rank your top three areas of interest/expertise from the career focus areas below, for the creation  of mentoring matches and/or Affinity Groups. (RANK YOUR TOP 3 CHOICES ONLY - even though the list goes to 12)

* 5. What is your current practice setting?

* 6. Please indicate your name and contact information.