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* 1. Name of your Team?

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* 2. Name of the EM Society?

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* 3. Address of your EM Society?

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* 4. Do the participants have any previous Simulation based education experience?

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* 5. Name of the Team Members and PG Year (Only four names are allowed with one each form PGY 1, PGY2, PGY3, and the fourth team member can be from any PGY year between 1 to 3/4).

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* 6. Team Leader Contact Details

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* 7. I hereby disclose that all the above information is accurate and can be verified. I understand that in case any information is found incorrect, then our entry to the SimWars will be denied and the SimWars team registration fee will be forfeited.

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* 8. Date & Time

Date / Time

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* 9. Enter your name to sign this form

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