Residency Program Registration Contact Information For Fair CommunicationName(Required) Title(Required) Mailing Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Comments/Special RequestContact Information For Printed Fair MaterialsIf different from above, please provide contact information for printed materials. same as above Name Title Phone Email Program InformationResidency Program Name(Required) Residency Specialty(Required) Emergency Medicine Family Medicine Internal Medicine Internal Medicine/Pediatrics Obstetrics and Gynecology Pediatrics Surgery Program Website Instagram Account AttendeesAttendee Names and Titles(Required) Add RemovePaymentRegistration fee: $300. Please indicate your method of payment. You will be contacted for payment information.(Required) Check Credit Card Checks should be made payable to UAMS; please indicate “Primary Care Residency Fair” in the memo line. Please mail checks to Tammy Henson-Platt, Rural Practice Programs Administrator | 4301 West Markham Street, Slot 551, Little Rock, AR 72205.You will be contacted for credit card information.