Illinois Downstate 2011 Associates Day Registration
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1. Friday, November 11, 2011
Spalding Pastoral Center
419 N.E. Madison Avenue
Peoria IL
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1
. First Name
First Name
*
2
. Last Name
Last Name
3
. Status:
Status:
Medical Student
MD
DO
MBBS
*
4
. Email Address
Email Address
*
5
. Residency Program or Medical School
Residency Program or Medical School
UIUC
UICOM Peoria
SIU
Other (please specify)
6
. Year
Year
PGY-1
PGY-2
PGY-3
Chief Resident
MS I
MS II
MS III
MS IV
7
. Membership Category
Membership Category
Master
Fellow
Member
Associate Member (medical residents)
Medical Student Member
Other (please specify)
8
. Participation (click all that apply):
Participation (click all that apply):
Attending General Session &/or Breakout Sessions
Presenting Poster
Presenting Oral Clinical Vignette
Doctor's Dilemma Team Member
Attending Complimentary Lunch on Friday
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