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* 1. First Name:

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* 2. Last Name:

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* 3. Major/Program:

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* 4. Organization/University:

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* 5. Home Address Line 1:

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* 6. Address Line 2:

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* 7. City:

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* 8. State:

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* 9. Zip Code:

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* 10. Home County of Residence:

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* 11. Phone Number:

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* 12. Email Address:

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* 13. How did you learn about the Indiana Rural Health Association Fellows Program? (Check all that apply):

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* 14. My areas of interest are (Check all that apply):

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* 15. In an effort to make your experience more fulfilling, please indicate a topic/field of interest that you would like to focus your research project on (i.e.: rural economic development):

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* 16. Are you currently a member of the IRHA? 

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* 17. I understand that if accepted to the Indiana Rural Health Association Fellows Program, I must be a member of the Indiana Rural Health Association or be willing to join before the start of the program. Membership must last for the duration of the program. 

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* 18. I understand that if accepted to the Indiana Rural Health Association Fellows Program, I must cover my driving expenses to two meetings in Indianapolis and one meeting in French Lick, IN. Lodging, event registration, and meals will be provided by the Indiana Rural Health Association. 

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* 19. Please attach a personal statement of 500 words or less that describes your particular interests and issues in rural health. How might your participation in the Policy Fellows Program enable you to address these issues? *

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* 20. Please attach a curriculum vitae/resume.*

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