CME REGISTRATION FORM

 

COURSE ON COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING

 

November 1st and 2nd, 2007

 

The fee for the entire course is $550 and includes early morning and mid-session refreshment breaks on both days and a syllabus of brief abstracts.  A check for the entire fee should accompany this application and should be made payable to “RUSH UNIVERSITY MEDICAL CENTER.”  A limited number of fellows and residents will be accepted for a fee of $425.00.

 

 

First name___________________________________________________

 

Last name___________________________________________________

 

Address_________________________________________________

 

City___________________  State________  Zip___________

 

Telephone______________    Fax________________   e-mail____________________

 

Institutional Affiliation______________________________________

 

 

_____ Radiologist

_____ Neurologist

_____ Neurosurgeon

_____ Administrator

_____ Technical Representative

_____ Other(Please specify) _________________________________

 

_____ Check if resident or fellow (Verifying letter required)

 

 

Mail to: Michael S. Huckman, M.D.

                        Department of Diagnostic Radiology and Nuclear Medicine

                        Rush University Medical Center

                        1653 W. Congress Parkway

                        Chicago, IL 60612