Sdran Mentoring Program

OCRA MENTORING PROGRAM Mentee Application Form

Please complete this form and email it along with your resume to us at [email protected]. You can also use this email address to send in any questions you may have about the program.

To qualify as a Mentee for the mentoring program, you must: 1. Be a current OCRA member and have been one for at least one year 2. Either live or work in California 3. Be willing to participate in the program for a period of 6 months from the date you are matched with your Mentor

** Please note that the information on this application form will be shared with a potential Mentor.

OCRA will make every effort to match you, as a Mentee, with a Mentor. Please note we may not be able to match you with a Mentor immediately. GENERAL INFORMATION

Are you currently an OCRA member?

Yes No

How long have you been a member of OCRA?

______years

Applicant Name:

Personal Address:

Business or Place of Work:

Business Address:

Job Title:

Other contact information (email address required):

Email Address:

Home Phone:

Cell Phone:

2 CAREER INFORMATION

Highest Level of Education:

Declared Major:

Total Experience in Life Science (years):

Total Experience in Regulatory (specify industry segment):

Total Experience in Quality Assurance (specify industry segment):

Total Experience in Clinical:

Highest Level of Functional Responsibility:

Total Number of Staff Reporting to You (if applicable):

Describe in detail the field or area(s) in which you would like to receive mentoring as a participant in the OCRA Mentoring Program (e.g., Regulatory, Clinical, Quality Assurance, Validation, CMC). The more specific you can be, the better we can match you with the appropriate Mentor. Keep in mind that most professionals have expertise in a specific area.

Do you seek mentoring with one or more of the following product areas (please rank area of interest if more than one)?

_____ Drugs

_____ Biologics

_____ Devices

_____ Combination Products

3 ______Describe at least one and up to three important goals you hope to achieve by participating in the OCRA Mentoring Program.

I declare that everything stated in this document is true. I have also attached the requested resume* and other documents to aid in the evaluation.

Print Name: ______Signature: ______

Date: ______

(*Please submit an up-to-date resume with current contact information.)