<p> 2016 Kanal’s Clinical MR Physics January 17-21 • The Antlers at Vail 4 Easy Ways to Register</p><p> 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</p><p>*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.</p><p>ATTENDEE INFORMATION (please print legibly and check boxes below)</p><p>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 </p><p>______Email address REGISTRATION FEES</p><p> 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</p><p>______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.</p><p>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.</p><p>SPECIAL NEEDS OF DISABLED PERSONS</p><p>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 </p>