Please SUBMIT this entire form no matter which payment plan you choose to ensure a complete registration.

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.
First Time Participation:

Previous Participant:

No, I will send you a check for $700 (or $400 if I participated in last year's review course.)

• If you are paying by check, we expect payment within 2 weeks to hold your spot.:
• Print out this page (or your confirmation page) and return in an envelope with your check for $650.00 payable to:
  Consultants in Nuclear Medicine
  2910 W. Estes Avenue
  Chicago, IL 60645

Registration: Annual Review in Radiation Physics for Radiology Residents

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

I learned about this course:
Flyer in Mail
A Colleague
Website

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

Security Code: