1.Name:

2.Institution:

3.Current Educational Status:

4.Career Objective:

5.What brings you to our mentoring program? How did you hear about Chem WMN?

6.Have you had or do you currently have a mentorship relationship (as a              mentor or mentee)? What benefits have you received as a result of this relationship?

7.What are some criteria by which you would want to be matched with a mentor?

8.What are your top two concerns with regards to pursuing a career in academia?

a.Pursuing independent funding, writing grants, designing research projects

b.Managing students

c.Work-life balance

d.Having a family

e.2-body problem

f.Working in a male dominated field

g.Teaching, designing course materials, giving lectures

h.Something else:____________________________________

9.Please list a few of your interests and activities on and off campus.

10.Anything else you want us to know in order to provide you with a better match?

11.Do you have a specific mentor you would like to work with?

12.What is your preferred method of interaction with your mentor and others at Chem WMN (email, phone, skype, etc.)?