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The Eastern - ENRS

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<strong>The</strong> <strong>Eastern</strong> Neuroradiological Society<br />

Twenty-First Annual Meeting<br />

August 20-22, 2009<br />

<strong>The</strong> Hotel Hershey, Hershey, Pennsylvania<br />

Annual Meeting Registration Form<br />

(Please print legibly or type)<br />

Name:<br />

Nickname (for badge):<br />

Institution:<br />

Address:<br />

City: State/Province: Zip/Postal Code:<br />

Phone: Fax: E-mail:<br />

REGISTRATION FEES<br />

Please indicate appropriate meeting registration fee below (U.S. Funds only). Please make check payable to <strong>ENRS</strong>.<br />

<strong>ENRS</strong> Member $175.00 Non-member $350.00<br />

Fellow/Trainee $100.00 Spouse/Guest $75.00<br />

Form of Payment<br />

Credit Card Number<br />

Check/Money Order Visa MasterCard American Express<br />

Expiration Date<br />

Signature<br />

Spouse/Guest Information<br />

Name of Spouse/Guests) Attending, (if applicable)<br />

I will attend: Thursday Dinner (# attending ; # children attending ; age of children )<br />

Dietary Restrictions:<br />

Friday Reception/Dinner (# attending ; # children attending , age(s) )

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