Mentor Connection

Please complete this form. Your information will be posted on the Office of Surgical Education's website for interested mentees to connect with you.

First & Last Name*

Please attach your photo

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Credentials

May select multiple credentials.

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Professional Title*

Academic Rank

Please include a short bio

Division*

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Section

Years in Practice

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Areas of Interest*

What areas are you interested in mentoring in? May select multiple.

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If Other...

Please list any other areas of interest you would be interested in mentoring.

Education History

Please list your undergrad, grad and post grad.

How many mentees are you interested in mentoring at one time?*

Please list your email address*

Where is your office located?

If possible, please also list a room number.

Administrative Assistant's Phone Number

Administrative Assistant's Email Address

Please list your professional interests*

Personal Interests*

Please provide a few personal interests so that mentees can get to you know you better.

Twitter Handle