Mentee Questionnaire

Massachusetts Dental Society

Two Willow Street
Suite 200
Southborough, MA 01745

(800) 342-8747
(508) 480-0002 fax

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Mentee Questionnaire

* Required

 

* Full Name:   

    

* Preferred Address:   

   

* City:   

* State:   

* Zip:   

    

* Phone:

* Email: 

* Home State: 

* Dental School Attended: 

* Year of Graduation:

Post-Graduation Plans (if currently in dental school): 

 

* Practice Setting Desired: 

If practice setting is "Other," please specify:

Expected Practice Location: 

Armed Forces: 

 

* Leadership/Volunteer Positions Held: 


* Non-Dental-Related Hobbies: 


Professional Interests (e.g., organizations, research, medical conditions, etc.): 

 

* Do you own or have access to a car? 

* How far are you willing to travel to meet with your mentor? 

* What is your preferred method of contact? 

 

* What do you hope to gain from the Mentor Program? 


* How important is it that your mentor is a member of your district? 

 

* Would you consider attending a district meeting with your mentor? 

 

* What is the most important criteria you are looking for in a mentor? (e.g., specialty, gender, ethnicity, location, practice setting, method of contact, etc.)

  

 

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