Name Work Address Contact email Telephone number BFS Member No Current Role Experience relevant to becoming a mentor Mentorship offered: (Circle all that apply) Andrology (clinical scientist)CounsellingFertility NursingReproductive MedicineUrology/Clinical AndrologyEmbryologyManagementOther (please state) Education History (Including qualifications) Employment History Relevant skills I confirm that I have been working for a minimum of 3 years as a professional in fertility in any of the categories above and 3 years post-registration YesNo I give permission for my email address to be given to a Mentee, to be allocated by BFS YesNo I agree to provide feedback to BFS on an annual basis YesNo I agree that I will not comment on issues relating to work disputes/difficulties in training YesNo I will not provide a formal reference for job applications (as a BFS Mentor) 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