10th Anniversary/Pre-Faculty Career Development Conference Registration Please complete the following form to register for the conference. Before December 14 full refund possible. Between December 15 – December 31, 50% refund on registration. After January 1 no refund for registration. 2020 BNGAP 10th Anniversary and 2nd National Pre-Faculty Conference Registration Type*College Student/Post-Bacc (Only Attending Career Advising Session, Thursday 5-6PM, Jan 30, 2020) FREECollege Student/Post-Bacc (copy of valid ID or letter required) $30Medical/PhD Student (copy of valid ID or letter required) $150Resident (copy of valid ID or letter required) $175Fellow $200Physician/Dentist $350Other Health Care Professional $250Gala Only $75Scan of ID/LetterIf necessary, please upload a scan of your valid ID or another official letter which designates your status.Accepted file types: pdf.Will pay later?YesWho will be paying for you?*For college or post-bacc students: Would you like to meet with a medical school or dental school admission officer?YesNoFor graduate students, residents and fellows: Would you like to meet with a residency recruiter or faculty recruiter to discuss opportunities at their institution?YesNoFor junior faculty: Would you like to meet with a senior faculty member or administrator to discuss career development?YesNoIf yes, which specialty are you considering or currently practicing?Name* First Last Email* BioIF APPLICABLE, if speaker, moderator, or award recipient, please include bio here (limit to 150 words)BNGAP username*If you have not yet registered for BNGAP.org, please write "Not registered"Position/Title*Institution*Street Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificOtherZip Code*CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwePhone*Race/Ethnicity* White Asian Native American/Alaskan Native Hispanic/Latino Black/African-American Prefer not to answer Other Specify if OtherBirth sex*MaleFemaleIntersexOtherPrefer not to answerSpecify if OtherSexual Orientation*Straight or heterosexualGay or lesbianBisexualOtherPrefer not to answerSpecify if OtherGender Identity*WomanManTransgenderDifferences of Sexual Development (DSD)Genderfluid/Gender non-conformingOtherPrefer not to answerSpecify if Other We are working with host institution leaders to try and identify trainees who are willing to host out-of-town participants conference participants.If applicable (your institution is hosting), are you willing to host an out-of-town participant?YesNoCriteria for hostingDo you have any specific criteria for hosting (gender, etc)?If applicable (you are coming from another institution), would you like to receive information on staying with a host trainee or faculty member?YesNoWould you be willing and interested to carpool to the sites with other participants?YesNoFood allergies*Please include any food allergies Your total registration feePlease press submit to continue to Paypal to complete your registration. $0.00 EmailThis field is for validation purposes and should be left unchanged.