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About
Board of Directors
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Member Information
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Last Name
*
First Name
MI
*
CPMSM?
Yes
No
*
CPCS?
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Other Credentials?
Work Title
*
Facility/Firm
*
Work Address - Line 1
Work Address - Line 2
*
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*
Zip
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Work Telephone
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Work Fax
*
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Background Information
*
Type of health care facility, managed care organization, CVO, etc.
*
Medical Staff Size
Work Experience:
*
Year in Present Position
*
Years in Health Care Field
*
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