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First Name

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* 1. First Name

Middle Initial

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* 2. Middle Initial

Last Name

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* 3. Last Name

What licenses do you hold? (i.e. RN, MD, SW, etc.)

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* 4. What licenses do you hold? (i.e. RN, MD, SW, etc.)

What are your professional credentials? (i.e. PhD, MSN, BSN, LMSW, BA, etc.)

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* 5. What are your professional credentials? (i.e. PhD, MSN, BSN, LMSW, BA, etc.)

Your employer's Name

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* 6. Your employer's Name

Your job title

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* 7. Your job title

Work address

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* 8. Work address

Your work City, St & Zip

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* 9. Your work City, St & Zip

Your home address

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* 10. Your home address

Home City

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* 11. Home City

Home State (please abbreviate)

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* 12. Home State (please abbreviate)

Home Zip Code

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* 13. Home Zip Code

What is your preferred mailing address?

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* 14. What is your preferred mailing address?

Provide your primary email address

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* 15. Provide your primary email address

Provide a secondary email address
if you don't have one go to next question

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* 16. Provide a secondary email address
if you don't have one go to next question

What is your medical specialty? (i.e.pediatrics, geriatrics, diabetes, obgyn, etc.)

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* 17. What is your medical specialty? (i.e.pediatrics, geriatrics, diabetes, obgyn, etc.)

What topics interest you?(i.e. Nursing Skills, Leadership, Medical Updates, Women's Health, etc. feel free to add your own topics)

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* 18. What topics interest you?(i.e. Nursing Skills, Leadership, Medical Updates, Women's Health, etc. feel free to add your own topics)

Please click yes if we can include you on all of our email announcements by sending an email.
Click no if you do not allow us to email you (we will remove you from the list)

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* 19. Please click yes if we can include you on all of our email announcements by sending an email.
Click no if you do not allow us to email you (we will remove you from the list)

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