REGISTRATION
NMRI Southern Region Workshop
October 3-5, 2007
Online Registration Deadline - Friday, September 21, 2007
Registration is closed.
All fields followed by a * are required
Speakers and NMRI guests, please register below.
Prefix (Ms., Mr., Dr.):
First Name*:
Middle Initial:
Last Name*:
Degree(s)*:
Title/Postition*:
Department:
Organization*:
Divisions:
Street Address*:
Bldg./Mail Stop:
City*:
State/Province*:
ZIP/Postal Code*:
Country (if other than U.S.A.):
Telephone*:
Fax:
Email*:
TTY/TTD:
Special (ADA needs):
Dietary restrictions:
Are you currently a member of NMRI?*
Yes
No
Current funding source:
Federal Grant
Foundation
University
Private Industry
Other
If Federal Grant, please specify agency.
If other, identify source of funding.
What is your current level of academic achievement?*
Fellow/Resident
Instructor
Assistant Professor
Associate Professor
Professor
Medical Student
Post-Doc
Other
If other, please specify.
Areas of expertise or research interests (select all that apply):
Diabetes
Hematology
Nephrology
Urology
Kidney
Nutrition
Endocrinology
Metabolism
Digestive diseases
Other
If other, please specify.
What influenced your decision to attend?
Topic
Purpose
Networking
Location
Other
If other, please specify.
Poster*:
I will be participating in the poster presentation
I will NOT be participating in the poster presentation
Please
Click HERE
for instructions on submitting an abstract.
The following questions are optional:
Which of the following most closely reflects your racial origin?
African American
American Indian/Alaska Native
Asian American
Caucasian
Native Hawaiian or other Pacific Islander
Other
If other, please specify.
Please check if your ethnicity is Hispanic/Latino.
Yes
No
Gender
Male
Female
**
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This page last updated on 3/29/2007.
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