PAMED Mentor/Mentee Program Application

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First Name: *

Last Name: *

Email: *

Organization/Practice Name: *

Street Address *

Street Address

City *

State *

Zip *

County Affiliation

Phone Number *

Clinical Specialty

(n/a if student)

Organization/Practice Setting *

Academic Health Center

Ambulatory care center

government/ insurance

group practice

health system

hospital

independent private practice

physician/ hospital organization

research/ pharmaceutical

N/A

Other:

What is your career stage? *

Medical Student

Resident or Fellow

Early Career Clinician (up to age 45)

Part-time clinician & Part-time management

Full time management

late career clinician (planning to retire within 5 years)

Retired

Other:

I want to be: *

a Mentor

a Mentee

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