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* 1. Name and Credentials

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* 2. ACS Member ID Number (if applicable/known)

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* 3. Institution/Organization

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* 4. Business Address

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* 5. City

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* 6. State

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* 7. Country

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* 8. Zip Code

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* 9. Email

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* 10. Phone Number

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* 11. Specialty

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* 12. What other ACS committees are you applying to? (you may apply up to 2)

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* 13. Please list other ACS Committee(s) you currently serve on

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* 14. Describe why you want to serve as a member of HPAG

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* 15. Please send your CV or bio sketch to cbloom@facs.org

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