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* 1. What is your first name?

* 2. What is your last name?

* 3. What is your phone number?

* 4. What is your mailing address?

* 5. We are considering running medical courses in the following places. Please check all that you might be interested in

  Would Attend Maybe Wouldnot attend
New York
Toronto
Atlanta
San Francisco
Australia
United Kingdom
Amsterdam
Portugal
Japan
Hong Kong

* 6. Is there any location you would like to suggest?

T