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First name
Last name
Email address
Phone number
Selections
Please make a single selection from the choices below
Location
QLD
NSW
ACT
VIC
SA
TAS
WA
NT
Years of experience in the industry
6 months or less
up to 1 year
1-2 years
2-3 years
3 years +
Title
Doctor
Nurse practitioner
Nurse
Authorised Prescriber
SAS-B
None
How many hours a week would you be interested in
0 –5
5-10
10-20
20-30
30-40
What days would you be interested in
Monday – Friday (9am-5pm)
Monday – Friday (5pm – 10pm)
Weekends – (9am-5pm)
Other notes