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1. Contact Information

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2. Year in practice / Academic Rank (if applicable)

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3. Where did you do your Fellowship Training?

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4. Where did you do your residency?

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5. Which career track best describes you?

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6. Which practice mix best describes you?

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7. What is your career blend?

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8. What types of cases do you perform? (select all that apply)

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9. Select all that apply so we can best match you

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10. What are your career interests?

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11. What are your interests outside of work?

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12. Why do you want to participate in this program?

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13. To participate, you need to attend the ASRM meeting. By checking this box, you confirm attendance.

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