2022/2023 PLA Application
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Email *
Full Name *
Mobile Phone Number *
Emergency Contact Name and Phone Number
Practice Name, Street Address, City
Specialty/Sub Specialty
Why are you interested in participating in PLA and what do you hope to accomplish in your year of study?
What is your highest aspiration as a physician?
What qualities, skills and/or experiences do you offer your fellow participants and what specific knowledge, skills and/or experiences do you hope to receive in return?
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