SCIENTIFIC/SOCIAL REGISTRATION - RADIOLOGY IN SICILY
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        Business Telephone               Fax Number
                                     

REGISTRATION FEES

Scientific fee which includes social functions: $1,765.00
Social Registration (spouse, friend, family member): $325.00 
Children up to 13 years: $250.00 
Total:  

 There will be no refunds after August 20, 2010. Before then there will be a cancellation fee of $100.00.

                  
Type Card                                Security Code                                                     Card # or Check #                                          Exp. Date
                                               
 

Authorized Signature:

Total $ Enclosed

If you have special needs please note them here.
 
Please print and mail with your check or money order payable to: Radiology International, Inc, 225 North Main St.., Bristol, CT 06010 Ph: 860-584-9197 or 800-942-4080.
To pay by credit card fax to 860-314-2943 or mail to Radiology International, Inc. You can also scan and e-mail to sylviap@globetvl.com