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Please
fill in the form as completely as possible.
* indicates required field.
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NOTE: Please be sure to specify your
opt-in/opt-out choices using the yes/no buttons below. This information
is also being used for your online directory entry.
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Name
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*
Last Name:
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*
First Name:
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*
Initial:
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Prefix:
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Home
Address
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*
Address 1:
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Address 2:
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Address 3:
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*
City:
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State (Province, Region):
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ZIP (Postcode):
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Country:
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Yes
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No
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Display
street address to STRP members/Affiliates
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Other
Contact Information
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Home Phone:
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Format:
(570) 555-1111
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Preferred E-mail:
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Secondary E-mail:
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Website:
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Degree
and Specialty Information
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. Preferred
Class Year:
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First degree/residency/fellowship
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Type:
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Graduation or Completion Year:
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Major or Specialty:
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Second degree/residency/fellowship
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Type:
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Graduation or Completion Year:
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Major or Specialty:
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Third degree/residency/fellowship
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Type:
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Graduation or Completion Year:
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Major or Specialty:
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Fourth degree/residency/fellowship
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Type:
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Graduation or Completion Year:
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Major or Specialty:
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Other/Secondary Specialty:
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Yes
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No
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Display
degree(s) to STRP members/Affiliates
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If you
graduated with a later class, or in some cases, early . in December of
the year prior, but have an affinity with your "entering" year
class . you may identify a "preferred" class year for the
purposes of class mailings and reunion information.
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Practice/Business
Information
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Employer Name:
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Job Title:
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(ie. Medical Director, V.P., etc)
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Address 1:
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Address 2:
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Address 3:
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City:
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State:
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ZIP (Postcode):
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Country:
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Work Phone:
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FAX:
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Format:
(570)555-1111
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Classnote
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(Update
your classmates on what you've been doing, career highlights, and family
news).
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