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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
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