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* 1. Please type your full name

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* 2. Email address:

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* 3. What is the date of your application?

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* 4. What is the title of your special interest group?

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* 5. Provide the BACKGROUND information. What need does this issue/proposal address (ASPMN/member/patient/other)

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* 6. In reference to question #5; With which ASPMN goal(s) does this align? (please mark those that apply)

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* 7. Describe what resources will be needed to bring your proposal to fruition. What is the financial impact to ASPMN (i.e. cost, income, or neutral)?

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* 8. Who will be the main SIG Coordinator? Please provide project leader’s name/email and other participants/committee affiliation if applicable. 

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* 9. What other resources are needed to bring this project to completion (e.g. ASPMN management company, technology services, legal services, other committees, volunteers)?

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* 10. How will you recruit new members? Please check all that apply.

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