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**SUBMIT this page to SMH Personnel Form: Students DEMOGRAPHICS Name:DOB:Mailing Address: City:State:Email Address:Zip:Phone:EDUCATIONMedical Studentship: PA or NP Studentship: Health Science Student

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What is submit this page to?

This page must be submitted to the appropriate regulatory body or authority.

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Any individual or entity that is mandated by law or regulations to submit this page.

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The purpose is to provide necessary information to the regulatory body for compliance or reporting requirements.

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