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Professional Details

Graduate of		Year	1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Highest Degree		Employer

	Physician
Speciality	---Select One---- Allergy/Immunology Anesthisiology Cardiology Dermatology Emergency Medicine Endocrinology Family Practice Gastroenterology General Primary Care Infectious Disease Internal Medicine Neurology/neurosurgury Obstetrics/Gynecology Occupational Medicine Oncology Opthmalmology Orthopedics Otorhinolaryngology Pathology Pediatrics Psychiatry Pulmonology Radiology,diagnostic Rhumatology Surgery Surgery cardiothoracic Surgery plastic Surgery, vascular Urology Other (physician)	DEA #

	Pharmacist
Speciality	---Select One---- Retail Hospital Consultant Managed Care Student Faculty Other	State Lic#		(Optional)
Licencing State	---Select One---- AK Alaska AL Alabama AR Arkansas AZ Arizona CA California CO Colorado CT Connecticut DC District of Columbia DE Delaware FL Florida GA Georgia HI Hawaii IA Iowa ID Idaho IL Illinois IN Indiana KA Kansas KY Kentucky LA Louisiana MA Massachusetts MD Maryland ME Maine MI Michigan MN Minnesota MN Montana MO Missouri MS Mississippi NC North Carolina ND North Dakota NE Nebraska NH New Hampshire NJ New Jersey NM New Mexico NV Nevada NY New York OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina TN Tennessee TX Texas UT Utah VA Virginia VT Vermont WA Washington WI Wisconsin WV West Virginia WY Wyoming

	Nurse
Profession	---Select One---- Faculty Hospital Hospital Administrator Managed Care Private Practice Student Other	State Lic#		(Optional)
Licensing State	---Select One---- AK Alaska AL Alabama AR Arkansas AZ Arizona CA California CO Colorado CT Connecticut DC District of Columbia DE Delaware FL Florida GA Georgia HI Hawaii IA Iowa ID Idaho IL Illinois IN Indiana KA Kansas KY Kentucky LA Louisiana MA Massachusetts MD Maryland ME Maine MI Michigan MN Minnesota MN Montana MO Missouri MS Mississippi NC North Carolina ND North Dakota NE Nebraska NH New Hampshire NJ New Jersey NM New Mexico NV Nevada NY New York OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina TN Tennessee TX Texas UT Utah VA Virginia VT Vermont WA Washington WI Wisconsin WV West Virginia WY Wyoming

	Other
Profession	---Select One---- Audiologist Chiropractor Medical Researcher Occupational Therapist Optometrist Physical Therapist Physician Physician Assistant Podiatrist Neutritionist/Dietician Rehab Specialist Resperatory Therapist Social Worker Student Technician Other medical/clinic

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