2016 Resident Advocacy Program Registration

Photo credit: CC-BY-SA-3.0/Matt H. Wade at Wikipedia

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* 1. I would like to register for:

June 6 - 7, 2016 - ACOG District II + March of Dimes Lobby Day

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* 2. Contact Information

Name & Credentials:

Program Year:

Email:

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* 3. Please indicate your home address so we can determine your legislative district

Street:

City:

Zip:

County:

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* 4. Residency Program Information

Hospital:

Program Director Name:

Program Director Email:

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* 5. Will you require hotel accommodations?

Yes

No