2019 Resident and Medical Student Forum Poster Presenter Registration Form

Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

NYACP Resident and Medical Student Poster Presenter Registration Form

Desmond Hotel
660 Albany Shaker Road
Albany, NY  12211

Saturday, February 23, 2019

Time
7:30 am                        Registration
8:00 am - 10:30 am    Poster Judging
10:30 am- 1:00 pm     Dr's Dilemma Competition

 

ACP Membership # *
First Name *
Last Name *
Credentials
Address *
City *
State *
Zip Code *
Phone
Office Fax
Email *
Title of Poster
If first author is not available; please include the substitute author below:
Senior Author Name: Please submit name below if you would like NYACP to acknowledge your Senior Author
Senior Author Email Address
Poster Presenter Registration Fee *

Clear Selection
Total
Name (As it Appears on Credit Card) *
Billing Address 1 *
Billing Address 2 (ie Apartment, Floor, Suite, etc)
City *
State *
Zip Code *

Payment Information

Amount to Charge :
Payment Method:




Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

image widget