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* 1. Please enter your contact information below (address listed below will apply as voting district)

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* 2. What is your membership with ACP?

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* 3. Which medical school are you part of?

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* 4. Which residency program are you part of?

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* 5. Do you have experience in advocacy?

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* 6. If yes, please describe.

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* 7. Have you registered for Leadership Day?

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* 8. I agree that I am a first time attending physician, student, or resident/fellow member

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