General Information

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* Email Address

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* Name, Affiliation and contact information of applicant.

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* Current designation and department. 

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* Are you a current IPTA member? (You need to be a current IPTA member in good standing to be eligible to apply. Please go to https://tts.org/ipta-members-area/ipta-join to become an IPTA member or to pay your dues. Your application will not be valid unless you are an IPTA member or have submitted an application to join IPTA)

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* Are you or is your institution currently signed up to the Declaration of Istanbul? (You or your institution needs to be signed up to the Declaration of Istanbul Custodians Group to be eligible to apply. Please go to http://declarationofistanbul.org/ to sign up. Your application will not be valid unless your institution is signed up to the DICG or has submitted an application to join the DICG)

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* Do you have any previous mentorship experience? If yes, please provide details (up to 250 words).

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* Discuss your reasons for applying as a mentor (up to 350 words)

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* What are the key areas of support you would be able to provide an international IPTA fellow/Emerging centre? This will help in pairing you with applicants. (up to 250 words)

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* Would international IPTA Fellows/ Emerging Centre faculty be able to participate in clinical rounds/case discussions with clinical teams at your centre? 

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* Would international IPTA Fellows/ Emerging Centre faculty be able to participate in hands-on procedures/surgeries at your centre (with supervision)?

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* Would international IPTA Fellows/ Emerging Centre faculty be able to attend case conferences /didactic sessions such as Grand Rounds at your centre?

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* Would international IPTA Fellows/ Emerging Centre faculty be able to have access to their own desk space and office supplies at your centre?

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* Would international IPTA Fellows/ Emerging Centre faculty be able to have access to the library and online literature search tools at your centre?

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* Would international IPTA Fellows/ Emerging Centre faculty be able to have access to additional funding support from the institution at your centre?

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* Indicate how much time you would be able to spend as a mentor per week (fill all that apply):

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