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Address
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Home Number
Fan Number
Date of Birth
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Board Certified (Y or N)
Board Eligible (Y or N)
Email:
Yrs. as Ringside Physician
Boxing Profession (if not a Ringside Physician)
Home Page: (if any)

Please include a $125.00 Application and Membership Fee For The Calender Year. 

                                    TAX ID # 13-4133577                                    

Send Check or Money Order to:

A.A.P.R.P. 

40 Heights Road

Suite 201

Darien, CT. 06820

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