Mississippi Academy for Simulation Training

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MAST Faculty Online Foundations Training Request Form

Requested semester of training *

Nominee Legal First Name *

Nominee Middle Initial *

Nominee Legal Last Name *

Email *

Phone *

Last 4 digits of the nominee's SSN *

Nominee's Date of Birth (MM/DD/YYYY) *

Is the nominee a current or former UMMC employee or student? *

Yes

If Yes, please provide the employee ID number.

Simulation Years of Experience *

Nominating Institution *

Nominating Administrator *

Administrator Email *

Administrator Phone *

Please list the name of alternate nominee, in the event the first nominee is unable to participate. *

Alternate's Email *