Prospective Mentor Application Form

Documents to submit:

1. CV.
2. Copy of malpractice insurance.
3. Copy of professional license in one state/jurisdiction.
4. Copy of ECS certificate.
5. Brief statement about philosophy of care in the area of EDX (3 sentences max).
6. Brief description (3 sentences max) of current EDX practice (incl. but not limited to):
   1. Type of clinical setting.
   2. Types of patient conditions encountered.
   3. Days/hours per week in EDX practice.
   4. Other.