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* 1. Name

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* 2. Residential address

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* 3. Phone number

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* 4. Email

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* 5. Please confirm your availability to participate in the program at the following times:

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* 6. Describe your practice (50 words)

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* 7. How do you see this program developing your practice? (50 words)

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* 8. Please provide your bio (150 words)

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* 9. What is it about Critical Light that most appeals to you? (50 words)

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