The Eastern - ENRS
The Eastern - ENRS
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) )