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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your email address?

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* 4. How much do you pledge to raise? To be considered for a place you must pledge to raise at least £1,500

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* 5. How will you raise money for the Association of Anaesthetists' SAFE programme? Give examples of past fundraising if applicable.

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