904 womens.indd - UCSF Department of Radiology & Biomedical ...

REGISTRATION
WOMEN’S IMAGING IN WINE COUNTRY (RAD 09 004)
October 12–17, 2008 / The Fairmont Sonoma Mission Inn & Spa, California
Early Enrollment Deadline: August 15, 2008
Four easy ways to register:
1. Online at www.cme.ucsf.edu
2. Phone using Visa, Amex or Mastercard. Call 415−476−5808, 8:30 am - 4:00 pm (Pacific Time)
3. Fax to 415−502−1795
4. Mail to UCSF Office of CME, PO Box 45368, San Francisco, CA 94145-0368
REGISTRANT INFORMATION (PLEASE PRINT)
Name _____________________________________________________________________________________
First Last Degree
Address ___________________________________________________________________________________
___________________________________________________________________________________
Tel _______________________________________
Area Code
Fax _______________________________________
Area Code
E-mail ____________________________________________________________________________________
Please add me to your priority email list.
Month/Date of Birth for record verification: _______ / _______ / X X
month date
COURSE REGISTRATION (RAD 09 004)
Check one: BY 8/15/08 AFTER 8/15/08
Physician $900 $975
Resident/fellow/nurse/sonographer/ $750 $825
technologist (with letter of verification)
METHOD OF PAYMENT
Check enclosed, payable to UC Regents.
Please charge my: Visa Mastercard American Express
Card No. ____________________________________________________________________________________
Exp. Date ____________________________
Signature ________________________________________
Payment may be made by credit card or by check or money order drawn on a U.S. bank in U.S. currency.
We regret that we cannot accept checks drawn on foreign banks. Enrollment Confirmation will be mailed to
you within two weeks of receipt of the application.
CANCELLATION
A refund of the enrollment fee, less $75, will be made upon receipt of a written request only by Friday,
10/3/2008. No refunds will be made after this date. In the unlikely event that the program is cancelled,
UCSF Radiology will refund the registration fee in full, but cannot be responsible for any hotel or travel costs.
11