| First Name: |
| Last Name: |
| Home Telephone Number: |
| Home Email address: |
| Home Address: |
| Home City: |
| Home State: |
| Home Zip: |
| Primary care Residency Specialty: |
| Date Primary Care Residency Was or Will be Completed: |
| Practice Name: |
| Practice Address: |
| Practice City: |
| Practice State: |
| Practice Zip: |
| Practice Telephone Number: |
| Practice Speciality: |
| Practice County: |
| Practice E-Mail Address: |
| Kansas Medical License Number: |
| Date Practice Began or Will Begin: |
| If you are changing locations, what date did you complete practicing at your prior location: |
Will you be working full-time, with full time being defined as 45 hours/week not including on call hours?
Yes No |
| If not, how many hours will you working (excluding on call hours)? |
| |
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