1. Name:


2. Title:


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

12. I am willing to mentor in the following ways: (check all that apply)
Assistance with 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 applications
Mentoring in the fields checked in #11
Other, please describe.

13. Type of Library or Department
Academic
Allied Health
Consumer Health
Corporate
Hospital
Nursing
Pharmaceutical
Other (please specify)

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

To send your application, press this button: