Mentorship Program Application

All fields are required.
Applicant Information
First Name:
Last Name:
Email Address:
Cell Phone:
What is your preferred method of communication?
Are you interested in being a Mentor or Mentee?
Mentor   Mentee
Current Location & Institution:
Current Position:
Plastic surgeon
Plastic surgery resident
Orthopedic surgeon
Orthopedic resident
Neurosurgeon
Neurosurgery resident
General surgeon
General surgery resident
Otolaryngologist
Therapist
Other (please specify):
Degree:
MD
PhD
MBA
MPH
MA/MS
BA/BS
Other (please specify):
Peripheral Nerve Surgery Research Interests:
Neuroma/chronic pain
Brachial plexus
Nerve compression
Trauma and reconstruction
Nerve tumor
Nerve machine interfaces and neuroprosthetics
Other (please specify):
Peripheral Nerve Basic Research Interests:
Neurobiology and nerve regeneration
Nerve machine interfaces and neuroprosthetics
Nerve tumors
Nerve reconstruction
Neuroma/chronic pain
Other (please specify):
CV:
Additional information to help us best match you with a mentor or mentee:


  		 
American Society for Peripheral Nerve
500 Cummings Center, Suite 4400, Beverly, MA 01915
Phone: 978-927-8330 | Fax: 978-524-0498