MENTOR INTEREST FORM
MENTOR INTEREST FORM1. In point form, indicate why you are interested in being a pharmacy resident mentor: (max 3 points)2. List below your leadership activities/experience: (if extensive, list 3 highlights)3. List three personal qualities you possess that you feel will contribute to your effectiveness as a mentor:4. Complete the following table related to education:Degree nameDate receivedSchool attendedEg. BScPhm2001University of Toronto5. Residency completed: YESNO (circle appropriate answer)If yes, which hospital?Year completed?6. Complete the following table related to pharmacy work experience:Job titleDatesLocationEg. Clinical Pharmacist2003-2006UHN-TGH –Surgery7. Have you been a residency pharmacy mentor in the past 3 years? If yes, who was your mentee? 8. (Optional) Indicate below if there is anything else you would like to add: (limit 100 words)Please submit completed form to Residency Coordinator(s) electronically Last updated August 2019 ................
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