29th Breast Imaging Conference

Registration Form

American Express

Mastercard

*Required Fields

REGISTRANT INFORMATION

*First Name:
*Last Name:
*Title:
*Facility:
*Address:
*City:
*Zip Code:
*Office Phone:	- - Extension:
To receive email updates please provide your E-mail address:
E-mail:
Home Phone:	- -
Fax Number:	- -

*PROGRAM FEES - Choose One:

Full Program:
	Administrator:	$550
	Doctor:	$640
	Resident:	$440
	Technologist:	$360

Single Day:
	Administrator:	$275
	Doctor:	$325
	Resident:	$225
	Technologist:	$185

Package Deals: Receive a discount for two registrations!
	Admin/Admin:	$1000
	Admin/Doctor:	$1100
	Admin/Tech:	$825
	Doctor/Doctor:	$1200
	Doctor/Tech:	$900
	Tech/Tech:	$695

Technology:
	Exhibits Badge Only:	$120

*If registering for a Package Deal, please provide information regarding the person who will be attending with you:	Name:
	Title:
	Facility:
	Email:
	Telephone:	- -

Workshops

All workshops run on Monday, September 14th at 10:30am, 1:00pm and 3:00pm

Digital Workshop:

All Digital Worshop Sessions are FULL.

MR Workshop:

I would like to register
for the MR Workshop.

Time:

Ultrasound Workshop:

I would like to register for
the Ultrasound Workshop.

Time:

Hands-on Mammographic Positioning Workshop:

I would like to register
for the Mammographic Positioning Workshop

Time:

Note: A separate confirmation letter with your designated time will be sent to you for entrance into the workshops. This confirmation is required to attend these workshops. Please be prompt as there will be a waiting list.

*PAYMENT - Choose One:

*If using a credit card for payment, please provide the following information:
Credit Card Holder Name:
Credit Card #:	- - -
Expiration Date:	/