2007 Kanal S MR Physics Course

2016 Kanal’s Clinical MR Physics January 17-21 • The Antlers at Vail 4 Easy Ways to Register

 Fax: (412) 647-0738 ➋ Phone: (412) 647-3510 ➌ Mail: University of Pittsburgh, Radiology Administration, Forbes Tower – Plaza Level, 3600 Forbes Ave at Meyran, Pittsburgh, PA 15213, ATT: Robin DeAngelo

*Return completed form with full payment by check, money order or credit card. Payment must be made in U.S. funds, drawn on a U.S. bank only and made payable to: Center for MR Education Note: Registration is confirmed and processed when payment is received. Confirmation will be e-mailed after registration is processed.

ATTENDEE INFORMATION (please print legibly and check boxes below)

Name ______Last NameP AYMENT I NFORMATION : Registrations First Name will not be processed without payment  MD  DO  PhD  RT  RN  Other ______AMOUNT: $______Last FIVE (5) digits of social security number (for CME/CE Check credits) enclosed (Make check payable to: Center for MR Education) ______VISA Mastercard American Express Discover  Office Card Number ______Exp. Date ______Card Security #______Institution/Company Name (as it appears on card) ______Cardholders billing address: ______Complete Mailing AddressCity ______State ______Zip ______City Signature: ______State Zip Code Date: ______Phone Fax

______Email address REGISTRATION FEES

 Home Note: Registration is confirmed and processed when payment is received. Confirmation will be e-mailed after registration is ______processed. Complete Mailing Address ______City State $1,295 Physicians, Scientists, and Industry Representatives Zip Code $950 Residents/Fellows in training, Technologists and Nurses ______Phone

______CANCELLATION POLICY E-mail address All cancellation requests must be made in writing. 1. Cancellations received in writing on or before December 17, 2015 will receive a full refund. 2. Cancellations received in writing after December 17, 2015, but before December 30, 2015 will be refunded the tuition fee less 25% service charge. 3. No refunds or credits will be available on or after December 30, 2015. No exceptions will be made.

VIDEO/AUDIO RECORDING POLICY Video and/or audio recording by course participants is not permitted during the lectures. Unauthorized recording equipment is not allowed in the meeting room.

SPECIAL NEEDS OF DISABLED PERSONS

Participation by all individuals is encouraged. Advance  Subspecialty: notification of any special needs will help us to provide better ______service. Please notify us of your needs at least two weeks in  I have worked with MRI’s for advance of the program. ______months/years  How did you hear about the course? ______FOR MORE INFORMATION ______Robin DeAngelo, Education Coordinator [email protected] http://mredu.health.pitt.edu Phone: (412) 647-3510 Fax: (412) 647-0738