ISVMA/CVM STUDENT-MENTOR PROGRAM
MENTOR INTEREST FORM

Date:

Name:

Company or Practice Name:

Title: (i.e. owner, associate, relief, etc.)

Address:

City: State: ZIP: County:

Phone: Email Address:

Homepage/URL:

Home Address (optional):

City: State: ZIP:

Phone:

Please indicate your practice areas of emphasis or specialization:

Food Production Animal Medicine

Bovine

Porcine

Dairy

Other (please specify )

Equine Practice (exclusive)

Large Animal (all species)

Companion Animal

Mixed Practice

Industry

Public Health

Regulatory Medicine

Military

Government

Academia

Exotics/Zoo Medicine

Other (please specify

What are your expectations of this program (i.e. reasons for becoming a mentor)?

Have you mentored veterinary students in the past? Yes No

If you have been a mentor, what do you think is the most valuable aspect of mentoring and can we share your thoughts with those who are doing it for the first time?

If specific requests can be met, is there a student(s) with whom you would like to be matched?

Student 1 Student 2 Student 3

What is your ideal number of mentees?

Can additional mentees be assigned to you if needed? Yes No

When would be a good time for us to contact with you if necessary (time of day, at work, at home?

Are you aware of a colleague who would be a good mentor candidate for this program.
(Please provide name and contact information.)

Comments: