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(please print legibly):

Mentee Name:  ___________________________________________________________
Affiliation:  _______________________________________________________________
Mailing Address:  __________________________________________________________
Telephone:  ______________________________________________________________
Fax:  ___________________________________________________________________
Email:  __________________________________________________________________

1. If you have a preference, please list your top five choices (#1 highest) for a Mentor.
1.
2.
3.
4.
5.

2. Below, please write a 3 to 5 sentence (maximum) description of your goals for participating in the 2004 Mentoring program.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

3. Please choose one of the following to describe your career goals over the next 5 years.
___ Research focused on ______________
___ Private practice
___ Geriatric administration
___ Education

4. Please indicate below what you are leaning towards as a primary career.
___ Solo private practitioner
___ Member of a group practice
___ Academic medical center
___ For-profit health care plan

5. Of the factors listed below, which are most important to you at the present time, from 1 to 5 (#1 most important).
___ My eventual career choice
___ Balancing family and career
___ Locating funding for research
___ My upcoming job search
___ Selecting between academic and community practice
___ Other, please explain _________________________

Please send a short CV (approx. 2 pages) along with your form. Return this form and your CV by fax to the attention of Elvy Ickowicz at 212-832-8646. Only complete applications will be reviewed.

Prior to the Annual Meeting, the AGS will forward to you the name and contact information of your 2004 Mentor. It will be YOUR responsibility to initiate contact with your assigned Mentor and for arranging a mutually convenient meeting time and place. It is our intention to provide both an interesting and informative opportunity for both Junior and Senior Faculty members.