1. Name:


2. For Students:
Degree/Major:
Library School:
Graduation Date:

3. Job Title:
Library / Institution:

4. Address:



5. Phone:


6. Fax:


7. E-mail address:


8. Are you a member of SC/MLA?
Yes
No

9. Are you a member of MLA?
Yes
No

10. Are you an AHIP member?
Distinguished
Senior
Member
Provisional
No

11. My professional interests include: (check all that apply)
Type of Work
Administration
Automation
Bibliographic Instruction
Cataloging
Collection Development
Consulting
Digital/ ElectronicResources
End User Training
Library Media (AV)
Online Searching
Reference
Serials
Web Mastery
Consumer Health Information
Other (please specify)

12. Type of Library or Department (where currently employed or where interested in working):
Academic
Allied Health
Consumer Health
Corporate
Hospital
Nursing
Pharmaceutical
Other (please specify)

13. I would like to receive mentoring in the following ways: (check all that apply)
Assistance with the AHIP application process
Conference buddy at SC/MLA
Conference buddy at MLA
Career guidance
Assistance with research / projects
Assistance with writing for publication
Assistance with grant writing
Mentoring in the interest fields given in #11
Other (please describe)
Which two mentoring options are the most important to you?

14. I prefer to be contacted by:
Email
Phone
Mail
Fax

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