Resident and Fellow Application Form

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Email (Required.)

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Name (Required.)

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Degree (Required.)

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Specialty (Required.)

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Have you attended PVTL in the past? (Required.)

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Are you applying as a Resident or Fellow? (Required.)

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What year are you in your program? (Required.)

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Organization/Institution (Required.)

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Position

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Address (Required.)

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Phone (Required.)

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Please add a few sentences as to why you would like to attend PVTL and what you hope to gain from attending this meeting. (Required.)

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How did you hear about PVTL?

Before completing your application, please read and agree to the terms below.

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I agree that if I am awarded a scholarship, I will attend the required sessions in full and complete sign-ins at designated sessions. I understand that my scholarship will be at risk of forfeit should I miss required sessions during the conference. (Required.)

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I agree that failure to send a cancellation request or attend PVTL in full will result in ineligibility for future scholarships opportunities at HMP Global conferences, which include but are not limited to the International Symposium on Endovascular Therapy (ISET), The Symposium on Clinical Interventional Oncology (CIO), Western Atrial Fibrillation Symposium (Western AFIB), and the Amputation Prevention Symposium (AMP). (Required.)

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I agree that if I am awarded a scholarship I will submit my travel itinerary including flight information as soon as I have confirmed my availability to attend the conference or by the published deadline. I understand that my scholarship will be at risk of forfeit should I fail to submit this information. (Required.)

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