**Additional sign-ups will be added to the waitlist of attendees

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* 1. Your full legal name as shown on your passport or driver's license?

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* 2. Your professional credential/s?

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* 3. What is your NPI Number?

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* 4. Your date of birth?

Date

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* 5. Your cell phone number?

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* 6. Your email address?

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* 7. Please name your primary workplace:

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* 8. ZIP code of your primary workplace:

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* 9. What MAC are you in?

T