Online Registration Form

Online Registration Form

Enter information in each field, press TAB to move to next field and click CONTINUE to complete your registration.

For your convenience, a "User ID" will be constructed from the first 4 letters of your Last Name + 4 digits you provide below. (It is recommended to use the last 4 digits of your SSN.)

* Required Field

* First Name

* Last Name

* User ID (Last 4 digits)

****

	* Degree MD DO PhD PharmD NP RN RT Other/Specify:

* Affiliation (Institution, School or Practice)

* Specialty

* Sub Specialty

Contact Information

* Address1
Address2
* City
* State	* Zip/Postal Code
* Country

* Email Address

* Primary Phone Number

Alternate Phone Number

Fax Number

Spouse Name

Please select all that apply below

* Attendee Type

Physician

Technologist

Full Time Active Military

VA Personal

Resident/Fellow
(Letter from academic institution required)

Dietary Needs

Kosher

Diabetic

Vegetarian

Alumni

Penn Radiology Alumni

      Residency
      Fellowship
      Both

Year Completed

Course Prices	Physicians	Discounted	Early Bird Before 12/15/07
Part I - Lectures	$695	$575	$670/$550
Part II - Individual Workstations to Review of 50 Cases	$995	$995	$900
Total Both Parts	$1690	$1570	$1570/1450
If interested in attending the lectures plus the Optional Case Review, please contact us directly at 215-662-6982 to register by phone. Limited space available for Case Review Option, please sign up early.

Fee

Payment will be processed through Secure Payment processing

Contact us at:
Registrar, University of Pennsylvania Medical Center, Department of Radiology
1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104
Phone- 215-662-6982 Fax- 215-349-5925 Email: tiffany.epps@uphs.upenn.edu