Personal Information: (Please enter only alphanumeric values
in the following fields.)
* Denotes Compulsory
Fields |
| *
Name: |
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* Address: |
|
| *
Year of Graduation: |
|
* State: |
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| *
Primary Specialty: |
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* Country: |
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| Secondary Specialty: |
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* Contact No.: |
|
| *
Preferred E- mail Address: |
|
Fax: |
|
| |
| * Your Principal Professional
Activity (Please check one only): |
|
Direct Patient Care |
Medical Teaching |
Research (non-Academic, related to medicine)
|
Research (academic, related to medicine) |
Biomedical entrepreneurship
or business
|
Medical/Health Administration |
Government/Health Regulatory
|
In transition |
Retired
Semi-retired
|
Other (Specify)
|
| Do you teach?
Yes
No |
|
| What percent of your time:
|
|
| |
|
| * Is your work setting in
(Please check one
only): |
Solo Practice
|
Group Practice |
Medical School/Teaching Hospital
|
Hospital |
Industry
|
Other
|
