Please complete all the information requested.

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* 1. Demographic

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* 2. Gender:

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* 3. Medical School attended- Name State Country, if not USA Dates of Attendance Graduation Date (month/year)

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* 4. Current Employer/City/State

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* 5. Position/ Years employed

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* 6. Select one or more of the following five groups:

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* 7. What is your motivation for choosing this program? What do you hope to gain from this curriculum?

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* 8. Tuition for the entire certificate program is $5,500. You may register for each section individually ($1900 per section). For payment arrangements please contact the Office of CME at 718-270-2422. Fee does not include books and required materials such as needles.

To pay by credit card, download the Payment Form.

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* 9. Which session are you applying for

I hereby certify that all the information given in this application is accurate and complete. I understand that all the information contained in this application will be treated confidentially and will be used for institutional purposes only. I realize that failure to provide complete and accurate information may affect my admission. I understand that my application will not be considered until all necessary documents are received by the Office of Admissions.

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* 10. Signature of Applicant

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* 11. Date

Date

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