Wisconsin Neuro Targeted SIM Registration UF/WIDI SIM Registration Form ProgramProgram - Name* Program - Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Residency Program DirectorResidency Program Director - Name* First Last Residency Program Director - Email* Residency Program Director - Phone*Program CoordinatorEach participating institution must specify an individual (frequently the residency program coordinator) who will serve as the institution's liaison. Each institution's liaison will be responsible for registering the program and residents; submitting payment; ensuring the workstations are setup and confirming system readiness; and scheduling each resident for the SIM.Program Coordinator - Name* First Last Program Coordinator - Email* Program Coordinator - Phone*ResidentsPlease enter the names of all residents that will be scheduled to take the SIM and specify current year in program (1st year resident; 2nd year resident; 3rd year resident; 4th year resident).Resident 1 First Last Resident 1 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 1 Email Resident 2 First Last Resident 2 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 2 Email Resident 3 First Last Resident 3 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 3 Email Resident 4 First Last Resident 4 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 4 Email Resident 5 First Last Resident 5 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 5 Email Resident 6 First Last Resident 6 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 6 Email Resident 7 First Last Resident 7 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 7 Email Resident 8 First Last Resident 8 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 8 Email Resident 9 First Last Resident 9 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 9 Email Resident 10 First Last Resident 10 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 10 Email Resident 11 First Last Resident 11 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 11 Email Resident 12 First Last Resident 12 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 12 Email Resident 13 First Last Resident 13 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 13 Email Resident 14 First Last Resident 14 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 14 Email Resident 15 First Last Resident 15 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 15 Email Resident 16 First Last Resident 16 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 16 Email Resident 17 First Last Resident 17 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 17 Email Resident 18 First Last Resident 18 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 18 Email Resident 19 First Last Resident 19 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 19 Email Resident 20 First Last Resident 20 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 20 Email Resident 21 First Last Resident 21 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 21 Email Resident 22 First Last Resident 22 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 22 Email Resident 23 First Last Resident 23 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 23 Email Resident 24 First Last Resident 24 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 24 Email Resident 25 First Last Resident 25 - Year in Program 1 - 1st year resident 2 - 2nd year resident 3 - 3rd year resident 4 - 4th year resident Resident 25 Email
