Registration Form

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You may register for the CCSNM 2010 Joint Meeting by using our secure online form below or downloading the PDF brochure. Early Bird Registration ends September 13th, 2010.

Registration Fees include program materials, continental breakfasts, breaks, reception on Friday and the lunch on Saturday.

Registrant Information:

SNM Member #:

First Name:

Middle Initial:

Last Name:

Degree:

ARRT	AS	BA	BS	CNMT
MD	MS	PhD	RPh	DO

Institution:

Department:

Address:

City:

State/Province:

Postal Code:

Country:

Telephone:

FAX:

E-Mail:

Registration Category:

Select only ONE	Registration Fees
Physician, SNM Member		$150
Physician, Non-SNM Member		$175
Physicist, SNM Member		$150
Physicist, Non-SNM Member		$175
Technologist, SNM Member		$120
Technologist, Non-SNM Member		$125
Resident		$40
Technologist Trainees		$10
Administrator		$40

Governance Meetings:
Please Check here if you plan to attend the governance meetings on Friday, October 1, 2010.

Method of Payment:

Credit Card:

Cardholder Name:

Card Number:

Expiration Date:

(mm/yy)

*When you using your Visa/MasterCard/American Express card, a Security ID Code is required to complete the transaction. The code on your Visa/MasterCard is located on the BACK of your credit card immediately following your account number in the signature area. It contains three digits. On your American Express card, the Security ID Code is located on the FRONT of your card, directly above the last 5 digits.

*Security ID:

Cancellation Policy: Cancellations must be received in writing by September 13th, 2010 to receive a refund, less a $25.00 cancellation fee. No refunds will be given for cancellations received after September 13th, 2010.