If you would like the AMA-RFS chair to send a letter thanking your program director(s) for permitting you to attend the AMA-RFS Assembly Meeting, please fill out the following information. If you would like the AMA-RFS chair to send a letter thanking your program director(s) for permitting you to attend the AMA-RFS Assembly Meeting, please fill out the following information. Contact Information RFS Attendee Information Name First Last Email Residency/Fellowship Program Program Director Information Name Title Title Title * Miss Ms Mr Mrs Dr Other… Enter other… First Last Organization Address Address Address 2 City/Town State/Province State * Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federate States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP/Postal Code Second Program Director Information Name Title Title Title Miss Ms Mr Mrs Dr Other… Enter other… First Last Organization Address Address Address 2 City/Town State/Province State Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federate States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP/Postal Code Leave this field blank
