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1
. First Name
First Name
2
. Last Name
Last Name
3
. Designation
Designation
4
. Address
Address
5
. City, State and Zip Code
City, State and Zip Code
6
. Phone #
Phone #
7
. e-mail
e-mail
8
. I am a . . .
I am a . . .
Physician
Emeritus Fellow
Young Physician (40 and under)
Resident
NP/PA/Nurses/Other
9
. I plan to pay by
I plan to pay by
Credit Card Online
Mail a check to 9905 Woodstock Street, Lenexa, KS 66220
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