Young Microsurgeons Group Application

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1. Contact Information

Name

Institution

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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2. What year did you start practicing after formal training?

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3. What year did you become board certified (if applicable)

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4. If you are not board certified, when is your intended certification date?

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5. Are you interested in serving on committees?

Yes

No

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