I wish to use a Credit Card- 
I will submit my payment with secure transmission using Paypal.com. If you do not have a paypal account, you can simply click on the check out links to use credit cards at that site.
Technologist

Physician or Administrator

  I wish to pay by check       Technologist: Check for $100 Physician: Check for $150 Administrator: Check for $150

• If you are paying by check, we expect payment before September 1, 2010 to hold your spot at this price.
• Print out this page (or your confirmation page) and return in an envelope with your check  payable to:
  Consultants in Nuclear Medicine
  2910 W. Estes Avenue
  Chicago, IL 60645

Registration: Emergency Preparedness for Radiological, Biological and Chemical Terrorism: Hospital Response

Name:  
Address:
City:     
State:       Zip Code:
Email Address              
Hospital or Clinic          
Daytime Phone or Pager
Work Fax                     
Special Notes               

Date I Plan to Attend:   October 17, 2010

To ensure a prompt processing of your registration,
please enter the security code below: