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Ions listed below, please enclose a detailed explanation.) 1. Do you have any pending misdemeanor or felony charges? M Yes M No 2. In the past three years have you been convicted of a felony? M Yes M No 3. In the past three years has your license to practice medicine in any jurisdiction been voluntarily or involuntarily denied, restricted, suspended, challenged, revoked, conditioned or otherwise limited? M Yes M No 4. M Yes M No In the past three years and up to and.

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