AUA Speed Mentoring Program

Young Urologists Forum

Mentee Application Form

* Required field

First Name*

Middle Name

Last Name*

Name Suffix (Jr., III, etc.)

Credentials (MD, PhD, etc.)*

Email Address*

Phone Number*

Address*

Address 2

City*

State*

Zip Code*

Country

AUA Member *

 Yes   No

AUA ID (If AUA Member)

AUA Section

   Mid-Atlantic

   New England

   New York

   North Central

   Northeastern

   South Central

   Southeastern

   Western

Education

Medical School*

End Date (MM/YYYY)

Residency*

End Date (MM/YYYY)

Fellowship/Specialty

End Date (MM/YYYY)

Fellowship/Specialty

End Date (MM/YYYY)

Employment

Current Affiliation/Practice*

Start Date (MM/YYYY)

Mentee Areas of Interest

(Please select five topics you would like to be mentored on)*

   Negotiating a Contract

   Choosing a Sub-specialty

   Finding a Job

   Academic Career

   Employed Physician vs. Private Practice Career

   Research Career

   Work/Life Issues

   Being a Surgeon Parent

   Leadership Skills

   Surgical Education

   Getting involved with the AUA

   Fundraising

   Effective Collaboration with APPs

   Advocacy and Public/Health Policy

   Approaches to the Disgruntled Employee