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* 1. Full Name

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* 2. Email Address

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* 3. Current University/ Institution

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* 4. Activity Name and Location

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* 5. Activity Dates

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* 6. Activity Description

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* 7. Short-Term Impact on Professional Development

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* 8. Long-Term Impact on Professional Development

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* 9. Please attach documentation showing participation in activity (Certificate of Attendance, Verification Email/Letter, etc.) 

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* 10. Attestation

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