ESGE Mentoring Programme - Mentee Application This is a one-year supporting program directed to GI endoscopists who would like to receive mentorship in their professional career development and/or research and academic development. The program aims to trigger diversity in our community and will seek to help specially the endoscopists who have had difficulties in findings mentors and/or role models in their close community and/or encounter difficulties related to their personal and/or economic or social conditions. This program is not an advanced endoscopy training and does not aim to improve or further the endoscopic skills. However, mentorship may provide exactly the support necessary to foster your career.Personal detailsTitle(Required)DrProfessorMrMsName(Required) First name Family name Email(Required) ESGE Member's ID Number(Required)Telephone number (with country code)(Required)e.g.+49 788 778976765Date of birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)FemaleMaleNon binary / gender diversePrefer not to discloseDisability(Required)NoYesPrefer not to disclosePlease specify and provide the percentage of your disability [%]Languages(Required) Please indicate your primary language What other languages do you speak fluently? Place of residence(Required) City Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands EducationWhere did you complete your medical education?(Required) University / Institution name City Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Do you have a PhD?(Required)YesNoSpecialty(Required)Gastroenterologist / EndoscopistSurgeon / EndoscopistPathologistOncologistHepatologistPaediatricianOther specialtyPlease specify(Required)WorkYears in clinical practice(Required)How long have you been practicing following completion of your endoscopy training?Less than 1 year1-5 years6-10 years11-20 years21-30 yearsMore than 30 yearsCurrent place of work(Required) Institution City Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Future place of work (if applicable)Characteristic of your main place of workYour institution's type(Required)PublicPrivateIs it academic hospital/center?(Required)YesNoYour practice's type(Required)Referral centerCommunity centerRural centerPosition(Required)Full-time consultantPart-time consultantFellowChief of departmentOtherPlease specify(Required)Percentage of your weekly schedule devoted to endoscopy(Required)25% or less26-50%51-75 %more than 75%Percentage of the above devoted to interventional endoscopy(Required)25% or less26-50%51-75 %more than 75%Main field of expertise if dedicated time to endoscopy is < 50%HepatologyBiliary/pancreatic diseaseIBDIBS/motilityGastrointestinal oncologyOtherMain field of expertise if dedicated time to endoscopy is > 50%Upper GISmall bowel - capsule endoscopySmall bowel - DAEEUSERCPLower GIDo you work at the university or have any other teaching responsibility?(Required)YesNoProfessional acquaintanceHave you ever participated in extracurricular programme(s) or activities?(Required)YesNoExtracurricurral programme(s) - please briefly specify(Required)Have you felt that a lack of opportunities has limited your career?(Required)YesNoLack of oportunities - please briefly specify(Required)Please select three the most important areas, you would like to gain from this program?Rank 1 - The most important(Required)Practical tips for solving daily clinical problemsAdvice and support on implementation good quality clinical practice locallyAdvice on training courses/opportunitiesCombining work/research/familyAdvice on career planningNetworking and contact with Key Opinion LeadersNetworking for research and innovationSupport and advice for study design and / or paper publicationAdvice and support for progressing in academia / teachingAdvice on developing leader skills and managingRank 2 - Less important(Required)Practical tips for solving daily clinical problemsAdvice and support on implementation good quality clinical practice locallyAdvice on training courses/opportunitiesCombining work/research/familyAdvice on career planningNetworking and contact with Key Opinion LeadersNetworking for research and innovationSupport and advice for study design and / or paper publicationAdvice and support for progressing in academia / teachingAdvice on developing leader skills and managingRank 3 - The least important(Required)Practical tips for solving daily clinical problemsAdvice and support on implementation good quality clinical practice locallyAdvice on training courses/opportunitiesCombining work/research/familyAdvice on career planningNetworking and contact with Key Opinion LeadersNetworking for research and innovationSupport and advice for study design and / or paper publicationAdvice and support for progressing in academia / teachingAdvice on developing leader skills and managingWould you prefer to be matched to a mentor from the same country of residence?(Required)YesNoNo special preferencesDocumentation (upload)All submitted documents must be in English and applicant must be fluent in the English languageCV (Resume)(Required)Please include your brief CV (1 file, maximum 1 page, PDF format, maximum file size: 1 MB) Accepted file types: pdf, Max. file size: 1 MB.Cover letter(Required)Please include your brief CV (1 file, maximum 1 page, PDF format, maximum file size: 1 MB) Accepted file types: pdf, Max. file size: 1 MB.Please ensure to address in your cover letter the following: 1. Where do you see yourself in 5 -10 years (professionally/personally)? 2. Do you have any particular preferences regarding mentor’s characteristics and qualities (i.e gender, nationality, language, field of expertise). If yes please specify? 3. If you don’t mind, tell us, in a few sentences, about yourself (family situation, hobbies, personality…). This information will help us to do a better matching.Photo of Applicant(Required)Please include your photo (1 file, jpg, gif, png format, maximum file size: 2 MB) Accepted file types: jpg, gif, png, Max. file size: 2 MB.Terms and conditionsESGE Privacy Policy(Required) I have read the ESGE Privacy Policy and agree to the terms & conditions.Please read ESGE Privacy Policy and agree to the terms & conditions before submitting your application.Do you allow us to use your data anonymously for future improvement of this program?(Required)YesNo