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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. ACP Number

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* 5. Biography (suggested limit 250 words)

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* 6. How will attending the Annual IMM benefit you and the patients you serve?

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* 7. Please provide an overview of patient care you provide to underserved communities (suggested limit 250 words)

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* 8. Do you provide care in a rural setting (defined as a community with 2,500 or fewer people)

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* 9. Please indicate your primary specialty (the area in which you spend most of your time in medicine)

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* 10. How do you define your primary focus?

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