Radiology International Inc.
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PLEASE COMPLETE ALL FIELDS THEN PRINT AND  FAX OR MAIL TO ADDRESS AT BOTTOM OF PAGE
SCIENTIFIC/SOCIAL REGISTRATION - RADIOLOGY IN CHINA
E-mail Address:
Full Name: Title: M.D. D.O. DR.

Companion Name(s):

Badge Name(s)(Print all names as you would like them to appear on name badges)


Address:

City, State/Province                                                                Zip/Postal Code            Country
           

Home Telephone Number                              Business Telephone Number                              Fax Number
                                      
       

For questions please email Radiology International, Inc. (click here to email) or call
1-800-659-0872 or 860-364-5020
REGISTRATION FEES

Please indicate appropriate program and social registration fees below: (U.S. Funds Only)

Scientific fee: $1,495.00
      

 
There will be no refunds after March 15, 2006.  Before this date there will be a cancellation fee of $100.00.
Payment Method
 Card # or Check #

 Exp. Date
 
Authorized Signature:
Total $ Enclosed
If you have any special needs please note them here.
PAYMENT INFORMATION - PLEASE READ INSTRUCTIONS CAREFULLY


If you wish to pay by check or money order, please print and mail along with your check or money order made payable to:
RADIOLOGY INTERNATIONAL, INC., 22 South Ellsworth Road Sharon, CT 06069 USA .

If you wish to pay by credit card, please complete, print and mail or fax to:
RADIOLOGY INTERNATIONAL, INC., 22 South Ellsworth Road Sharon, CT 06069 USA .
(Fax number: 860-364-5040) Phone number 860-364-5020 Toll free phone number (U.S.A.)800-659-0872