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National Rural Health Conference Nomination Form
First Name *
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Last Name *
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Discipline *
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University *
What year of study are you? *
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Email *
Please use one that you check regularly
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Phone
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What positions have you held in TROHPIQ or other rural health clubs?
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In 150 words or less, please explain why you would be the best candidate to represent TROHPIQ at the National Rural Health Conference? *
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Are you a TROHPIQ member? *
Thank you for your application.
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