MKSAP Live Online Study Hall 2 Registration Question Title * 1. Name Question Title * 2. ACP Number Question Title * 3. My Registration is for: Full registration One-week trial only Question Title * 4. Chapter Texas Georgia Ohio Missouri California Illinois New Mexico New York Other Other (please specify) Question Title * 5. Year your Board Certificate expires (Members) / Year you plan to take boards (Resident Members: IL Elite Status ONLY): Question Title * 6. How many times have you recertified in the past? * IL Residents ONLY-I am a Resident Member (or in a Fellowship program) preparing for boards Never; this will be my first time Once Twice More than two times My certificate has no term limit Other (please specify) Question Title * 7. Email address: Question Title * 8. Cell Phone (used only in case of emergency prior to a session): Question Title * 9. Mailing Address: Question Title * 10. * IL Resident Members ONLY: I am an Resident Member at one of the following Elite Status Residency Programs (Masters, Fellows, & Members can skip to the next question): Advocate Christ Medical Center/Univ of Illinois COM at Chicago Loyola University MacNeal Hospital Mercy Hospital & Medical Center Southern Illinois University University of Illinois, Chicago University of Illinois, Urbana/Champaign West Suburban Hospital Medical Center Westlake Medical Center Question Title * 11. How did you hear about MKSAP Live Online Study Hall? Email Blast Flyer News You Can Use Downstate Dialogue Colleague (please list name below) Moderator (please list name below) Name of referral: Done
