Name Work Address Contact email Telephone number BFS Member No Current Role I would like a BFS mentor because: I would like Mentorship in the following area (circle up to two categories) Andrology (clinical scientist)CounsellingFertility NursingReproductive MedicineUrology/Clinical AndrologyEmbryologyManagementOther (please state) Education History (Including qualifications) Employment History I give permission for my email address to be given to a Mentor, to be allocated by BFS YesNo I agree to provide feedback to BFS YesNo I understand that I may not get a Mentor in the category that I request YesNo I understand that the Mentor will not provide a reference, support work placements, or comment on issues relating to work disputes/difficulties in training YesNo I understand that the Mentor/Mentee relationship can be dissolved at any time at the request of either party and in any event will be dissolved after 2 years YesNo Δ