Georgia AG COVID-19 Program Volunteers

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* 1. Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Specialty

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* 3. I am a...

Active/licensed physician in Georgia

Resident

Retired physician

Medical student

Pharmacist

Fourth-year pharmacy student

PA

APRN

Nurse

Dentist

Medical office worker

Medical office administration

Other (please specify)

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* 4. Last four digits of your social security number