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J-1 Visa Refusal: Additional Information
I herby authorize the APPNA Young Physician and Advocacy/legislative Committees to contact Congressmen, My training program, U.S Department of State, Congressmen, other Government departments and legislative authorities (as deemed necessary) on my behalf.
Date of Birth
Reason for J-1 Application
Training Program Name
Residency Speciality (e.g., Internal Medicine, etc.)
Residency Program City
Residency Program State
Residency Program Director (PD) Name
Residency PD/Coordinator Phone Number
Residency PD/Coordinator E-mail
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