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* 1. Please provide your full name

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* 3. Please provide your phone number

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* 4. Affiliation (Physician, Resident, Medical Student)

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* 5. Organization / Practice Name

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* 6. Will you be attending the town hall event?

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* 7. If you have any questions or topics you would like Congressman Greg Landsman to address, please list them below

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* 8. How did you hear about this event?

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* 9. Do you have any special requirements or requests for the event?

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* 10. Would you like to receive updates about future Academy of Medicine events?

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* 11. Would you like to get more involved with the Academy of Medicine? (Select any or all areas that interest you)

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