Name*

Title*

Employer*

Email*

Address*

Phone*

1. Please provide a 3-5 sentence description of the publishing program you are affiliated with (field topic, number of journals,, member society or not, etc.). If you are not part of a formal publishing program, please state this explicitly and describe the organization, the range of clients you work for or types of projects you typically work on.*

2. Please provide a brief description of your role in the organization described in #1, and how long you have been in the role.*

3. Please provide a brief description of the benefits you hope to gain by participating in the Mentorship Program.*

4. Please describe aspects of your job where you feel a mentor might be able to offer some guidance, any knowledge or skills that you would like to gain, or areas on which you’d like to focus through the course of the Mentorship program.*

Please enter the text from the image into the box below*