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* First Name

* Last Name

* Degree

MD DO

* Medical School

* Year Graduated

* State of Medical License:
(current or past if retired)

* Medical License #:
(current or past if retired)

* Full Name of Workplace (or retired, N/A, etc.)

Preferred Mailing Address please select Home Work

* Address 1

Address 2

* City

* State/Province

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Medical Specialty:

Areas of Medical Activity
(check all that apply):

Clinical Practice

Education

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Administration

Finding Meaning in Medicine Groups
The following information is not shared with anyone; but it is very important for our funding to be able to keep track of the FMM groups. The most accurate way to do that is by knowing host names and group locations:

* If you attend or host an FMM Group, what town is the meeting held in? (If you are not part of a group, write ‘N/A’)

* Are you the host or what is the name of the Host of the FMM Group that you attend? (If you are not part of a group, write ‘N/A’)

If you are not already part of an FMM Group, are you interested in starting a group? (If yes, we will send you information)

Finding Meaning in Medicine Posting Delivery Options:
If you would like to have individual postings delivered to your personal email or RSS feed, you may subscribe to one of these options inside the Discussion Forums (after your registration is complete.) If you would like to receive Forum Discussion postings via email in synopsis form rather than individually, please indicate how often you would like to receive them:

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What is the sum of: 11 + 3    

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