MICRA Mentee Application

MICRA Mentee Application

Thank you for deciding to become a MICRA Mentee!!

It is in the best interest of the Michigan Cancer Registrars Association to offer to those
interested in earning their CTR credential to have the best chance to succeed and for current
CTRs looking to advance their careers the opportunity to seek guidance from seasoned
professionals. Please complete and submit this form to the MICRA Board for a mentor
assignment.

Personal Contact Information

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal

Current Employer Information

Education

Degree
Are you enrolled in a CRM/CIM Program?
Are you willing to work with a mentor: