Complete Conference Management, a division of UMA Education, Inc.

PALP 2019

May 17, 2019 | Sheraton New York Times Square Hotel | 811 7th Avenue, 53rd Street | New York, NY

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Personal Details

First Name: *

Last Name: *

Medical Center/Company: *

Are you employed by a hospital-based or a private practice?:*(Please select one)

Hospital-Based Practice Private Practice Other

title *

Designations: * (Select up to two degrees)

Hold the Ctrl key while selecting additional degree.

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Preferred Mailing Address 2:

City: *

State: *

Zip: *

Primary Email: *(Format: email@domain.com)

Telephone (Day): *(Format: XXX-XXX-XXXX)

Mobile Phone: *(Format: XXX-XXX-XXXX)

Country: *

Confirm Primary Email: *(Format: email@domain.com)

Secondary Email: (Format: email@domain.com)

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CONFIRMATION INFORMATION WILL BE SENT TO YOUR PRIMARY AND SECONDARY EMAIL ADDRESSES.
CERTIFICATE INFORMATION WILL BE SENT TO YOUR PRIMARY EMAIL.

Professional Information

Select a Profession:*(Please select one)

    	    
Physician
    	    
Nurse or Allied Health Professional
    	    
Fellow or Resident*
    	    
Industry or Non-clinical

US STATE OF PROFESSIONAL LICENSURE: *

US STATE OF PROFESSIONAL LICENSURE 2:

License #: What is this

SPECIAL SERVICES (ADA):What is this

In order to qualify and participate in the PALP 2019 Fellow/Resident Scholarship you must submit, from your program director, on letterhead, a letter confirming your residency/fellowship status together with the application. Please submit to mlescanofeher@ccmcme.com.

More Information

WHAT CONTRIBUTED MOST TO YOUR decision TO REGISTER? *

DO YOU REQUIRE A LETTER OF INVITATION FOR VISA PURPOSES?

HAVE YOU ATTENDED PALP IN THE PAST?

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Age Group*

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Registration Fees

Fee Description TOTAL
Registration Fee:
None
Optional Session Fee:
Discount Code
Total Due: