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What is this applicant s current specialty 2. Date began employment in this specialty mmyy 3. Is this applicant check one private practice /self-employed employed full-time part-time or stipend employee If part-time or stipend please provide the average hours worked per week 4. a* If the applicant is a nurse describe the size/type of health care facility b. Describe the applicant s current work environment. If a student/resident describe course and/or clinical setting/environment 5. Select only ...

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