Fields with a * are required.
You must include data in those fields
or AAPS Online will be unable
to process this form.

*Name:

Title (including a brief job description):

Organization:

Address:

City:

State:

Zip:

*Telephone:

Fax:

E-mail address:

Preferred sex/racial/ethnic background of mentor (check as many as applicable):

Female:

Male:

American Indian/Native American/Alaskan:

Caucasian:

Asian Pacific/Islander:

Hispanic:

African American:

Other:

Please provide demographic information about yourself to aid in matching process

Preferred Mentor AAPS Section Affliation

AP:

BT:

CS:

EM:

MN:

PT:

PDD:

PPDM:

RA:

Preferred Mentor Characteristics

Respond to either or both sections by briefly describing mentor characteristics depending on type of mentoring you prefer (career development, AAPS involvement, etc.)

Professional Expertise: For example: industrial: research scientist, group leader, director, etc. academics: graduate student, post-doc, professor, etc.

Experience in AAPS: For example: Committee Chair, Executive Council Member, Past President, etc.

Is the geographical location of your mentor important to you?

Yes   No

Would you prefer a mentor who also works for your same employer?

Yes   No

Please suggest names of any individuals you would be comfortable with as mentors. The committee will contact these individuals without direct reference to your request to assess their interest in participating in the AAPS mentor program.