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LAST NAME
FIRST NAME
DEPARTMENT
EMAIL ADDRESS
Rank order the Academy's committees with 1 being the committee you are most interested in joining.
1
2
3
Membership Committee
Educator Development Committee
Building Community Committee
Which scholarly/research interests do you have in medical education related to the following domains? Please select all that apply.
Learner Assessment
Curriculum Development /Educational Program Design
Teaching Skills
Advising/Mentoring
Educational Leadership/Administration
Please include a brief description of any potential scholarly/research projects on which you are interested in collaborating. We would like to promote this on the Academy website. Please limit to 10-12 words.
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