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* 1. Name

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* 2. email address

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* 3. Phone Number

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* 4. License (check all that apply)

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* 5. I have participated  as a (check all that apply)

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* 6. Number of years judging at ClinCon

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* 7. Number of years judging any EMS competition

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* 8. Number of years as a competitor

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* 9. Certifications (check all that apply)

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