UCSF Breast Imaging course brochure (PDF) - ESR - Congress ...

RegistrationBREAST IMAGING / OPTIONAL DIGITAL MAMMOGRAPHY (RAD09013)January 11 − 16, 2009 / The Fairmont Orchid Hawaii, KonaEarly Registration Deadline: Friday, Nov. 14, 2008 / Cancellation Deadline: Monday, Jan. 5, 2009Four easy ways to register:1. Online at www.cme.ucsf.edu2. Fax this form to 415-502-17953. Mail this form to UCSF Office of CME, PO Box 45368, San Francisco, CA 94145-03684. Phone using Visa, Amex or Mastercard. Call 4150476-5808, 8:30 am − 4:00 pm (Pacific Time)REGISTRANT INFORMATION (PLEASE PRINT)NameFirst Last DegreeAddressStreetCity State/Zip Foreign CountryPhoneArea CodeFaxArea CodeE-mailPlease add me to your priority email list.Month/Date of Birth for record verification: / / XXmonthdateCOURSE REGISTRATION (RAD09013)Please check: BY 11/14/08 AFTER 11/14/08 Physician $900 $975 Resident/fellow/nurse/sonographer/ $750 $825technologist (with letter of verification) Digital Mammography $275 $275(Optional, separate fee, must also beenrolled in the Breast Imaging course)TOTAL $Register for both Breast Imaging (Jan. 11–16) and Imaging Update (Jan. 18–23) and save $125 on BOTHcourse registration fees. Call the Registration Office at the number above to register with the discount.METHOD OF PAYMENT Check enclosed, payable to UC Regents.Please charge my: Visa Mastercard American ExpressCard No.Exp. DateSignaturePayment 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 toyou within two weeks of receipt of the application.CANCELLATIONA refund of the enrollment fee, less $75, will be made upon receipt of a written request only by Monday,1/5/2009. 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.15