Payment Form / New Form

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This site allows credit card payment to UIC Famly Medicine for payment of registration fees or processing fees for requests such as copies of documents.

Please complete the following information to pay for services:

Organization Name (if applicable):

Cardholder First Name:*

Cardholder Last Name:

Cardholder Address:*

City:

State:*

Zip Code:

Email Address*

Your confirmation email will be sent to this address.

Telephone Number:*

Conference Title or Miscellaneous Fee Description:

Enter Amount Due:

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