PAFP/F: TGS Promotional Giveaway Entry Form

TGS Promotional Giveaway Entry Form

Please complete all of the fields shown below to the best of your ability to be eligible and qualify for entry:

YOUR NAME AND INFORMATION:

First:

Last:

Degree:

Cell No.:

Email:

Residency Graduation Year:

PLEASE NOTE: Email and Cell Phone No. information are only needed to contact winners. You will not be contacted for solicitation.

PLEASE TELL US A BIT ABOUT YOUR PRACTICE:

Practice Type:

If Other (Please Specify):

Location:

Region of PA: