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* 1. Membership Type

* 2. Last Name

* 3. First Name

* 4. Title/Degrees

* 5. University

* 6. Principal Faculty

* 7. Principal Department/Program

8. Supervisor (for Trainees)

9. Principal Hospital Appointment(s)

* 10. Mailing Address

* 11. Telephone Number

* 12. E-mail Address

13. Website URL

14. Biography (150 words max)

15. Key Publications (top 5 in last 3 years)

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