Chief Residents Survey Application

Chief Resident Application Survey for AOAO Meeting Funding

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* 1. Please provide your contact information below, include your first and last name, mailing address, email address and phone number. This information is required to notify you of acceptance and process your reimbursement.

First and Last Name:

Mailing Address:

Phone Number:

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* 2. Name of your residency training program.

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* 3. Name of your Program Director.

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* 4. How will you attend the Annual Spring Meeting, April 15-17, 2021 in Salt Lake City, UT?

In Person

Virtually

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* 5. Do you plan to continue your training in a fellowship?

yes

no

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* 6. If yes, please let us know where you will train so we may extend your free membership.

Fellowship program name:

Training complete month/year:

Specialty:

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* 7. If no, please give us your new practice information so we can make sure you receive the discounted member rate for your first year in practice.

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* 8. The Academy would like to add subject matter to future meetings of interest to our Candidate/Resident members. Please check below which topics are of interest to you.

Board Review Course

Contract Negotiation

Billing/Coding Lectures

Student Loan Repayment

Other (please specify)