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Print and Detach Registration Form

REGISTRATION FORM (MAY BE DUPLICATED)

Please print and complete the registration form, detach and return in an envelope with your check or money order payable to:

Consultants in Radiopharmacy
2910 W.Estes Avenue
Chicago, IL 60645

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____ I wish to attend the 3 day course. Enclosed is $195.00
____ I wish to attend the 2 day course. Dates: ________ Enclosed is $150.00
____ I wish to attend the 1 day course. Date: ________. Enclosed is $85.00


Name ____________________________________ SS # ______________________
Home Address_________________________________________________________
City______________________________ State ___________ Zip Code ___________
Work telephone # ______________ FAX #______________
E-MAIL Address ________________

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