Membership News 9th MENTORING PROGRAM – MENTOR PROFILE Please complete the information below so we can match your skills with the appropriate mentee. Name_________________________________________Telephone_______________ Address_______________________________________e-mail___________________ City, State, Zip_______________________________ Years in practice_________ Specialty (if applicable)_______________________ What do you hope to achieve by being a participant in a mentoring program? ___________________________________________________________________ ___________________________________________________________________ Please place a check mark on the line for answers to each question. What are your preferences for the protégé assigned to you? _____ Male _____ Female _____ General Dentist _____ Specialist If you checked specialist, please indicate what type._______________________ How would you like to communicate with your protégé? (Check all that apply.) _____ Telephone _____ e-mail _____ In Person Please check what aspects of dentistry for which you can offer assistance. _____ Education Debt _____ Finding an associateship _____ Learning about partnerships _____ Starting a Practice _____ Negotiating salaries _____ Teaching/research Return Form Email it to: ninth@ninthdistrict.org Fax it to: 914-747-1396 Mail it to: 364 Elwood Ave., Hawthorne, NY 10532 Alice/Membership & Communications Committee/Mentoring/mentor form SUBMIT NOVEMBER, 2018 23