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Title
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First Name
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Last Name
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Address
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City
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State
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DC
DE
FL
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HI
IA
ID
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PA
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VT
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WV
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Zip
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Phone (xxx-xxx-xxxx)
Fax (xxx-xxx-xxxx)
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County of Residence
-- County --
Other
Alachua
Baker
Bay
Bradford
Brevard
Broward
Charlotte
Citrus
Clay
Collier
Columbia
Desoto
Dixie
Duval
Escambia
Flagler
Gilchrist
Glades
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Hendry
Hernando
Highlands
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Levy
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Martin
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Polk
Putnam
Santa Rosa
Sarasota
Seminole
St. Johns
St. Lucie
Sumter
Suwannee
Union
Volusia
Walton
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Are you affiliated with an AHEC program office?
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No
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Are you a Healthcare Professional Student?
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No
License Number
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Employer Name
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Profession
-- Profession --
Adv. Reg. Nurse Prac.
Certified Nursing Asst.
Comm Hlth Worker
Clinical Nurse Specialist
Dental Assistant
Dental Hygienist
Dentist-DDS, DMD
Doctorate of Nursing Practice
Emer. Management
Emer. Med. Tech.
Health Administrator
Health Educator
Health Professions Student
Home Hlth Aide
Licensed Midwife
Licensed Prac. Nurse
Medical Assistant
Medical Tech.
Mental Health Counselor
Non-Health Professional
Nurse Midwife
Nutritionist
Occupational Ther.
Optometrist
Paramedic
Pharmacist
Pharmacy Tech.
Physician Assistant
Physician: DO
Physician: MD
Physicial Ther.
Psychologist
Radiologic Tech.
Registered Dietician
Registered Nurse
Respitory Therapist
School Personnel
Social Worker
Teacher
Substance Abuse Counselor
Tobacco Cessation Counselor
Other
Ethnicity/Race
-- Ethnicity --
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other/Undeclared
Sex
Male
Female
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Academic Faculty
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No
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Employer Type
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Community Clinic
Community Hospital
Correctional Facility
County Health Dept.
Family Practice Center
Home Health Care
Homeless Clinic
Hospital Clinic
Indian Health Services
Mental Health Facility
Migrant/Community Health Center
Nursing Home
Private Practice
Profession Association
Rehab Center/Services
Retired
School/Community College/University
Self-Employed
Social Service Agency
Other
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Password
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E-mail
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