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Applicant performed during the time period indicated above. Signature of Chief of Surgery Name of Chief of Surgery typed mm/dd/yy Diagnosis do not use CPT codes or abbreviations Procedure. The Active Members must each enclose a sponsoring letter with this application form. A complete list of one year s cases signed by the applicant and the applicant s Chief of Surgery must be enclosed. Signature of Active Member Name of Active Member Typed or Printed Return completed applications to Bonnie...

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