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MEMBERSHIP INTEREST FORM:
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Email
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Name
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Address
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Contact Phone Number
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Fax Number
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Admin Assistant Contact name
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Admin Assistant contact
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Primary Specialty
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Subspecialty
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Academic Title (Resident/Fellow/Faculty/APP/Pharm D)
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For Member in Training- Fill out Training dates ---to--- (MM/YY)
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Institution Name/Address
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Years in Practice after training
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PH Specialty trained (Yes/No and years if yes)
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Describe your interest in PPHNet and your PH experience. What would you like to gain from as well as contribute to PPHNet?
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