Health Conference First Name* Last Name* Email* Phone* Degree* Organization* Address 1* Address 2 City* State* Choose one AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip* Please click the box that best describes you:* General attendee NYITCOM alumni NYITCOM-affiliated faculty, instructor, or staff Medical resident or other health professions student Will you attend the dinner and tour at the Clinton Presidential Center on Sept. 6?* Yes No Do you wish to purchase additional event tickets at $100 per person? How many?* Choose one 0 1 2 3 4 5 6 7 8 How did you hear about our conference? (Check all that apply) Previous attendee Web search Email Mail (flyer/postcard) Social media Other Please specify: TOTAL: $ Please enter the characters displayed in the image below.* When you proceed to payment you will be redirected to New York Tech's Payment Processor. After you've completed your payment, you will be redirected back to www.nyit.edu where you will see the confirmation message. Proceed to payment