Breast Imaging in the Big Apple - ESR - Congress Calendar

❐ JULY 12-15, 2007 NEWPORT BEACH, CALIFORNIACourse Code: IICME-ABI071207 • IICME Tax ID #- 582226876____Practicing Physician (before June 11, 2007) $850COURSE ENROLLMENT:____Practicing Physician (after June 11, 2007) $895____Resident/Fellow Breast (before Imaging June 11, 2007) in the big apple $695Please ____Resident/Fellow make your check (after June payable 11, 2007) to the course code listed $750 for the meeting____Military/Retired you plan to (before attend. June All 11, foreign 2007) payments must be $695 made by adraft ____Military/Retired on a United (after States June bank. 11, 2007) Mail to: The International $750Institute forContinuing____Technologist/AlliedMedical Education,Health Prof.Inc.,(beforeP.O. BoxJune350,11,Springville,2007)AL 35146.$695FAX (205)467-0195.____Technologist/Allied Health Prof. (after June 11, 2007) $750p ____Sixth December Meeting (will 3-6, be 2012 verified new by Ryals york, & Associates) nyFREECourse Code: IICME-BIBA120312 • IICME Tax ID #- 582226876____Practicing One registrant per Physician form, please; (before photocopy November for others. 3, 2012) Please ...............$950print.____Practicing Physician (after November 3, 2012) .................$995____Resident/Fellow (before November 3, 2012) ...................$850First Name MI Last Name____Resident/Fellow (after November 3, 2012) ....................$895Please circle your title: MD DO PhD MPH RN RT(R) RT(R)(M)____Military/Retired (before November 3, 2012) ...................$850____Military/Retired (after November 3, 2012) .....................$895____Technologist/Allied AddressHealth Prof. (before November 3, 2012) ......$750____Technologist/Allied Health Prof. (after November 3, 2012) ........$795____Sixth City Meeting (will be verified State by IICME) ..................... ZIPFREEHome Phone with Area CodeOffice Phone with Area CodeOne registrant per form, please; photocopy for others. Please print.FirstFaxNameNumber__________________________MIwith Area CodeEmail________ Last Name _________________________________Please Hotel Reservations circle your title: at MD DO PhD MPH RN RT(R) RT(R)(M)Address _________________________________________________________________________________CREDIT CARD: ❐ Visa ❐ MasterCard ❐ Discover ❐ American ExpressCity State ZIP _____________________________________________________________________________Home Phone (_______) ___________________Office Phone (________) _____________________________Account No. & Expiration DateFax Number (_______) ___________________ Email _____________________________________________Please note that when using AmericanCREDIT Cardholders CARD: Billing p Address Visa p MasterCard p Discover p American Express Express, you will be charged a fee of 3.25%.Account No. _______________________________________________ Expiration Date __________________Cardholders Signature Billing Address __________________________________________________________________For $Signature _______________________________________________________ For $ ____________________Special Requirements: If you If you are physically are physically challenged and have OFFICE any special USE needs, ONLYplease list them here.challenged and have any special needs, pleaselist them here.REC D:________ CONF:________OFFICEREC’D_____________________________ AMT:$_________CHK.#:________CONF: __________________________________USE ONLYAMT: $ _____________________________CHK: ___________________________________