LMOA - April 17, 2019 - Communication Breakdown

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* 1. Attendee #1: Last name, First name  (example:  Doe, Jane)

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* 2. Attendee #2 (if applicable): Last name, First name

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* 3. Attendee #3 (if applicable):  Last name, First name

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* 4. Attendee #4 (if applicable):  Last name, First name

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* 5. Practice/Department Name:

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* 6. Are you an LMOA member?  (If you are a Lakeland associate or work at a Lakeland-owned practice, you are a member since Lakeland pays the membership fee on your behalf)

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* 7. Payment is expected by the day of the meeting.  How will you be paying?

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* 8. If you are a Lakeland team member, please enter your department/cost center number:

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* 9. Contact person's email address:

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* 10. Comments, questions, special dietary requests, etc.

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