FSO Mentor Application Form
Please complete if you are interested in serving as a mentor to an ophthalmologist or trainee through the FSO mentorship program.
Name
First Name
Last Name
Degree
Institution/Practice
Years in Practice
City, State
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Briefly describe your experience and what you feel would bemost relevant to the Mentorship Program.
Are you willing to provide correspondence to your mentee(s)either via phone or email at least once a month or on an as needed basis established by you and the mentee?
Yes
No
Are you willing to attend the Masters in Ophthalmologymeeting in June to meet with your mentee?
Yes
No
How many mentees would you be willing to be paired with?
Please list any additional information you would like toshare regarding your qualifications to serve as a mentor.
Submit
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