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CCPHIT Employer Interest Form
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* Indicates required question
Name of Organization
Your answer
Point of Contact (Name)
*
Your answer
Role at Organization
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Which of the following best describes your organization?
*
Clinical Setting
Health Care Management
Health IT
Non Profit Organization
State or Local Health Department
Educational Institution
Other:
Organization Website
*
Your answer
Briefly describe your need for interns and what kind of projects they might work on at your organization.
Your answer
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