2021/2022 PLA Application
Mobile Phone Number
Emergency Contact Name and Phone Number
Practice Name, Street Address, City
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?
Send me a copy of my responses.
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