SCRS Mentorship Program Intake Form

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1. What is your full name?

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2. What is your email?

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3. What is your current role?

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4. What organization do you work for?

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5. How long have you worked in clinical research?

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6. Where do you live? (ex. Scottsdale, AZ)

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7. Would you like to be a mentor or mentee?

Mentor

Mentee

Both/Either