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Developing Nurse Scientists
    
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Enter Your Information

Please complete the following enrollment form. Items marked by an (asterisk*) are required for processing your enrollment.

In order to receive credit for completing this course, you must set up a user account consisting of your email address and a password of your choosing. Your email address and password will serve as your login information, therefore choose a password that is easy to remember.

Title:
First Name: **
Last Name: **
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  EMAIL RULES:
Email must be in a valid form of email@email.com. You will need to enter your email twice in the boxes below; this helps reduce the possibility of typing in your email address incorrectly.
Email Address: **
Re-enter Email Address: **
       
Affiliation:
Highest Education Level Completed:
Discipline:
Research Experience:
Years in Research:
    
  PASSWORD RULES:
Password must be at least 8 characters long, have at least 1 number, have at least 1 upper and 1 lower case letter, and 1 special character listed here ( ?!@#$%^&*()_+|~=, ).
Password: **
Re-enter Password: **
    
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The collection, maintenance and use of the personal information you submit via this website is protected under provisions of the Privacy Act of 1974. As such, all personally identifiable information you provide shall be treated as confidential, shall be used only for the purposes for which it was intended and shall be protected from unauthorized disclosure to the full extent permitted by the Act.




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