Rural Surgery Mentorship Program - Mentee form

Name*

First Last

Address*

Street Address City Province Postal Code

Email*

Phone*

Institution*

Year Graduated or Anticipating Graduation from Residency*

Year Graduated from Fellowship Training (if applicable)

Subspecialty Training (if applicable)

Areas of Interest

Select your top three areas for mentorship from the following list*

Please hold down the 'Ctrl' or Command key to select multiple areas

If work-life balance is important to you, please specify below if you are married, single, if you have a young family, want to start a family, etc. (optional)

Please indicate which provinces you are interested in working in:*

Hold down the 'Ctrl' or Command key to select multiples

Please indicate if you have a preference of your mentor's career stage:*

Hold down the 'Ctrl' or Command key to select multiples

Please describe what you are looking for in a mentor and what you hope to gain from participating in this program (500 words max).

Please upload an abbreviated CV (no more than three pages)*

Max. file size: 256 MB.

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Rural Surgery Mentorship Program – Mentee form