Thank you for your interest in this Kansas ACEP program.

Note:  Upon completion of this survey portion of the application, you will be asked to email a current copy of your C.V. to dlantz@kmsonline.org.

You will also be asked to have your residency program director (residents) or department chair (for recent residency graduates) email a letter in support of your application to dlantz@kmsonline.org.

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* 1. Applicant Name

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* 2. City and state of residence

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* 3. What are your career goals (including planned practice location) for the next 5 years? (200 words or less)

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* 4. Describe your previous experience with leadership in medicine and the specialty. (200 words or less)

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* 5. Why do you want to complete the Kansas Leadership and Advocacy Internship? (200 words or less)

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