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TITLE OF ROTATION:
Full Name of Contact Person:
Full Address:
Telephone: (please use xxx-xxx-xxxx format)
Email Address:
Website Address:
Are you an AMSSM Member
:
HOUSING::
Benefits (Stipend, Insurance, Parking) :
Licensing Requirement:
Malpractice Insurance Requirement:
Special Topic Covered (i.e. Training Rooms, Prolotherapy, MSK US):
Level (i.e. Med. Std., Resident-year): :
Length of Rotation:
Methods of Assessment (Grades):
Number of Learners per Rotation:
Contact Time Prior to Start of Rotation:
Comments
Please enter the Email Address from where you are submitting this form:
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