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* 1. Member Name:

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* 2. Member Phone #

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* 3. Member Email Address

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* 4. I'm interested in facilitating on the following dates - choose all that apply

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* 5. I will host

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* 6. Please provide information on the facility, business or private residence where you will be facilitating the webcast(s)

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* 7. Total number of nurses who can participate at this location

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