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* 1. Membership Type

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* 2. Last Name

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* 3. First Name

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* 4. Title/Degrees

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* 5. University

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* 6. Principal Faculty

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* 7. Principal Department/Program

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* 8. Supervisor (for Trainees)

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* 9. Principal Hospital Appointment(s)

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* 10. Mailing Address

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* 11. Telephone Number

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* 12. E-mail Address

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* 13. Website URL

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* 14. Biography (150 words max)

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* 15. Key Publications (top 5 in last 3 years)

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