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* 1. Last Name

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* 2. First Name

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* 3. Degree

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* 5. Institution

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* 6. Department/Program/School

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* 7. Current Research Focus

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* 8. Email

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* 9. Primary Contact Phone Number (numbers only, no spaces or hyphens)

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* 10. Have you taken any of the workshops below?

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* 11. If you took any of the above, please enter the completion date (if N/A, please enter N/A in the field).

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* 12. Please tell us of your teaching experience below. (Select all that apply).

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* 13. If you entered any teaching experience above, please tell us what was your target audience. (Select all that apply).

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* 14. Please select all areas you would be interested in teaching/lecturing. (Select a maximum of 5).

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* 15. Please enter any Scientific Technical Expertise (for example, PCR, or microscopy)

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* 16. Please check your willingness to participate in the areas below at local colleges and/or universities.

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* 17. Please upload your current curriculum vitae.

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