Please complete this form to determine your eligibility to participate in the MSV Survey on Assisted Suicide.

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* 1. Profession

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* 2. Name (First and Last)

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* 3. Email

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* 4. Daytime Phone

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* 5. Your County or City of Residence

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* 6. State 

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* 7. Are you a current member of the MSV?

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* 8. Specialty or Board Certification

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