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* 1. Name: 

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* 2. Current Role: 

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* 3. Specialty and Credentials:

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* 4. Preferred Contact Number: 

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* 5. Email Address:

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* 6. Present Employer: 

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* 7. Number of years in practice:

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* 8. Please specify any leadership program(s) you have previously participated in:

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* 9. Why do you want to participate in this program? 

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* 10. Anything else we should know in regard to your application? 

Please complete the scholarship questionnaire along with the online program application by January 15, 2023.

Questions can be directed to Corey Martin, Vice President, Education

Iowa Hospital Association | 100 East Grand, Suite 100 |
Des Moines, IA 50309

Email: martinc@ihaonline.org | Phone: 515-288-1955
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