Online Registration Form

Online Registration Form
please note: this form designed to work with Internet Explorer 6.0 and may not work with other browsers

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)

Alumni

Penn Radiology Alumni

      Residency
      Fellowship
      Both

Year Completed

Tuition Options

Select Option	Physicians	Discounted	Early Bird
MRI Course (Mon-Thurs)	$850	$750	$800/$700
Breast only	$450	$450
Body only	$450	$450

Fee

Payment will be processed through Secure Payment processing

Contact us at:
Registrar, University of Pennsylvania Medical Center, Department of Radiology
1 Founders/3400 Spruce Street, Philadelphia, PA 19104
Phone- 215-662-6982 Email: cme@rad.upenn.edu