Name *

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Last

Email *

Phone *

Your Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Academic Background and Professional Experience

Current Position *

Company/Organization *

Please provide a brief description of your position. *

Highest Degree

• Bachelors Degree
• Masters
• Doctorate

Area of Academic Specialization *

Mentoring Information

Please select from the list below the areas you would like to be mentored on. *

• Career planning
• Networking and profile building
• Working internationally
• CVs and applications
• Publication process
• Securing research funding
• Equality/diversity
• Professional behavior
• Academic acculturation
• Promotion and progression
• Managing challenging situations and conversations
• Work-life balance
• Other

Are there any other issues or challenges which you would like to address with your mentor? *

Please provide a 200-300 word biography. *

What are your career goals and objectives? *

Why do you want to be a mentee? What do you hope to achieve from it? *

Please provide any additional information that you feel will be useful for the matching process (interests, hobbies, etc). *

To get the full benefits of the mentorship program we ask that you commit to meeting with your mentor at least one hour per month, and communicating with your mentor at least once a week either by e-mail or telephone. Please select your hours of availability. *– Please select –9am-12pm CST12pm-6pm CST

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