SCIENTIFIC/SOCIAL REGISTRATION - RADIOLOGY IN PRAGUE and VIENNA.

Simply fill in application below and send to your printer. (See instructions below, thank you.)

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 contact 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)

Before November 1, 2007 Scientific fee which includes social functions: $1,445.00 
After November 1, 2007  Scientific fee which includes social functions: $1,645.00
                                                    Social Registration (spouse, friend, family member): $325.00    

 There will be no refunds after March 18, 2008. Before then there will be a cancellation fee of $100.00.

Payment Method                  Security   
                                                Code

Card # or Check #

Exp. Date
 

Authorized Signature:

Total $ Enclosed

If you have special needs please note them here.

 


To pay by check or money order, please print and mail along with your check or money order payable to:  RADIOLOGY INTERNATIONAL, INC.,  22 S. Ellsworth Road, Sharon, CT 06069

To pay by credit card, please complete, print and mail  to: RADIOLOGY INTERNATIONAL, INC.,  at the above address or fax to 860 364 5040.