Mentee Application
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the address?
Home
Work
School
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is this number?
Home
Work
Cell
School
Age (Optional)
Gender (Optional)
Languages Spoken
Ethnicity (optional, include if you feel this is important in your mentorship relationship)
Education (college / university, dental or other medical training, orofacial pain or other advanced / post graduate education, degrees earned and year)
Professional Status
AAOP Fellow
ABOP Diplomate
ABOP Board Eligible
If not ABOP Diplomate, are you preparing to take the board exam and are you looking for guidance within the mentorship relationship?
Yes
No
Other specialty or board certifications
Place of employment (and/or school attending)
Brief description of current career
Percent of current career dedicated to orofacial pain patient care
Percent of current career dedicated to sleep medicine patient care
Percent of current career dedicated to general dentistry patient care
Percent of current career dedicated to oral medicine patient care
Percent of current career dedicated to other patient care
Percent of current career dedicated to teaching
Percent of current career dedicated to research
Percent of current career dedicated to other
Areas of orofacial pain and/or dentistry or medicine of particular interest to you, or that you hope to learn more about or improve on? Any specific challenges you are currently facing in your career?
What do you hope to gain from the mentorship program?
Are you willing to travel to visit the practice of your mentor? (note: all travel is at the expense of the participants and strictly between them to arrange; AAOP does not provide any funding or official oversight of travel)
Hobbies and other Interests
AAOP committee membership. Every participant is required to be a member of an AAOP committee; if you are not already, indicate which committee you would like to join.
Other involvement/leadership in AAOP
Do you have any concerns that may impact your ability to participate fully for the approximately 10-month duration of this program?
Any additional factors that you would like to have considered in mentorship matching?
How often would you like to communicate with your mentor? Days or times that work best to communicate
Preferred Method of Communication
Phone
Email
Skype/Facetime/Zoom
Other
Attach a photo (Optional)
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