Registration for Regional Surgical Symposium in Tampa FL, February 3-4, 2023

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* 1. Your full legal name as shown on your passport or driver's license?

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* 2. Your professional credential/s?

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* 3. What is your NPI Number?

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* 4. Your date of birth?

Please enter date (MM/DD/YYYY)

Date

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* 5. Your cell phone number?

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* 6. Your email address?

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* 7. Please state the name of your primary workplace:

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* 8. ZIP code of your primary workplace:

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