Program Name*This is how your program name will appear in our program and on all signage.Program Director Name*Please provide name with credentials Program TypeResidencyFellowshipAddressAddress Line 2CityState- Select a State -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip CodeEmail* Phone*On Site Representative* First Last Email* On Site Representative* First Last Email* I will be attending the 2017 AOCPMR Fellowship and Residency Fair on Saturday, May 6 from 11:15-12:00pm in Hollywood Beach, FL at the Margaritaville Resort. Yes No I understand there is no fee to register or participate. Yes No By submitting this application, I acknowledge and agree on behalf of myself and the fellowship or residency training program: 1. The American Osteopathic College of Physical Medicine and Rehabilitation (AOCPMR) is organizing the Fellowship and Residency Fair for the convenience of residency programs and osteopathic medical students. 2. The fact that students, residents and/or training programs are permitted to participate in the Fellowship and Residency Fair does not in constitute endorsement of their qualifications and no advertisements or announcements implying such endorsements will be permitted. 3. AOCPMR makes no representations or warranties concerning the Residency Fair. 4. The Fellowship and Residency Program agrees to hold harmless, and shall not seek remedy from the AOCPMR. The Residency Program understands that the AOCPMR has disclaimed all liability for damages, costs and expenses, including legal fees that may be incurred because of its participation in the Residency Fair, regardless of the cause, effects or fault.