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* 1. Contact Information

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* 2. Employment Information

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* 3. Interest in Health Information Exchange

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* 4. By checking this box, I hereby promise that I am joining this council for the purpose of collaboration, and that I will be respectful of all council members’ thoughts and opinions. I further promise that I am not joining the council for any purpose that is adverse to the THSA’s stated purpose under Chapter 182 of the Texas Health & Safety Code. I recognize that I may be removed from the council for violating these promises.

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