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First Name:
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Last Name:
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Email Address:
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Mailing Address:
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Best Contact Phone Number:
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Are you a board-certified family physician?
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No
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Please check which volunteer opportunities you are interested in participating (check all that apply)
ABFM Engagement Network
Item Writing
Standard Setting
Optimize ABFM Website
Physician Portfolio Redesign
Focus Groups - Virtual
Focus Groups - In Person
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Briefly describe why you are interested in volunteering to help the ABFM in its continuous improvement process:
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Mailing Address
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Organization:
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Address Line 1:
Street Address, P.O. box
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Address Line 2:
Ste, Bldg, Apt, etc.
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Address Line 3:
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Address Line 4:
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City:
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State:
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Alabama
Alaska
American Samoa
Arizona
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
California
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Dist Columbia
Florida
Georgia
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Hawaii
Idaho
Illinois
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Iowa
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Maryland
Massachusetts
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Pennsylvania
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Texas
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Washington
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Province:
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Zip/Postal Code:
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Country:
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Afghanistan
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Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Arctic Ocean
Argentina
Armenia
Aruba
Ashmore and Cartier Islands
Australia
Azerbaijan
Bahamas
Bahrain
Baker Island
Bangladesh
Barbados
Bassas da India
Belarus
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian
British Virgin
Brunei
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Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
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Clipperton Island
Cocos (Keeling)
Colombia
Comoros
Congo, Democratic Republic of
Congo, Republic of
Cook Islands
Coral Sea Island
Costa Rica
Cote d'Ivoire
Cuba
Curacao
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Ethiopia
Europa Island
Falkland Island
Faroe Islands
Fiji
French Guiana
French Polynesia
French Southern and Antartic Lands
Gabon
Gambia, The
Georgia
Ghana
Gibraltar
Glorioso Island
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican)
Honduras
Hong Kong
Howland Island
Iceland
India
Indonesia
Iran
Iraq
Israel
Ivory Coast
Jamaica
Jan Mayen
Japan
Jarvis Island
Jersey
Johnston Atoll
Jordan
Juan de Nova Island
Kazakhstan
Kenya
Kingman Reef
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Man, Isle of
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Midway Islands
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Navassa Island
Nepal
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pacific Ocean
Pakistan
Palestinian Authority
Palmyra Atoll
Panama
Papua New Guinea
Paracel Islands
Paraguay
Peru
Philippines
Pitcairn Island
Qatar
Reunion
Russia
Rwanda
Saba
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Sint Eustatius
Sint Maarten
Solomon Islands
Somalia
South Africa
South Georgia and the Sandwich Islands
South Sudan
Spratly Islands
Sri Lanka
Sudan
Suriname
Swaziland
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tromelin Island
Tunisia
Turkey
Turkmenistan
Turks and Caico
Tuvalu
Uganda
Ukraine
United Arab Emirate
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Wake Island
Wallis and Futu
West Bank
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Yemen
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Zambia
Zimbabwe
Country Required