AABB PEP Mentoring Program Application

AABB PEP Mentoring Program Application

Please complete the form below to apply for the AABB PEP Mentoring Program
Full Name *

First Name Middle Name Last Name
Member ID# *
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Email Address *
Phone Number *

Area Code Phone Number
Title and Company *
What field do you currently Practice in? Check all that apply *

Cellular Therapies Patient Blood Management Transfusion Medicine Blood Banking
How long have you been in the field? *

New position (mentee) Less than 5 years (mentee) 5-10 years (mentor) 10+ years (mentor)
What are your interests in the field? Check all that apply. *

Quality/Regulatory Management/Administration Manufacturing Testing Collection Cord Blood Novel Therapies Research
How did you hear about this opportunity?

Program Goals and Expectations
My goals for this program are...
I would like my mentor/mentee and I to discuss...
These topics are considered off limits
I expect my mentor/mentee to...
The amount of time I can spend in on this program is...
I believe this program will help with my professional advancement by...
Please attach a copy of your CV. *

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PLEASE NOTE: This is an interdisciplinary program. While we will match you based on the details provided in this application, it is likely that the person with whom you will be matched will have a different background than you.*
Additional Commments

Mentoring Program Agreement
I have read and understand the Mentoring Program Handbook and agree to participate in AABB's mentoring program. As a mentor/mentee, I agree to comply with AABB's code ethics and mentproing program agreement.

If I am unable to fulfill my six month committement, I am obligated to contact the Volunteer Coordinator immediately and understand that I will not be issued a Certificate of Completion at that time. I will however be invited to return to the Mentoring Program at a more conducive time.
Name *
Date *
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Program Goals and Expectations