2021/2022 PLA Application
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Email address
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Full Name
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Mobile Phone Number
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Emergency Contact Name and Phone Number
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Practice Name, Street Address, City
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Specialty/Sub Specialty
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Why are you interested in participating in PLA and what do you hope to accomplish in your year of study?
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What is your highest aspiration as a physician?
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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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Send me a copy of my responses.
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