Clip & Mail
Registration Form D e c e m b e r 1 3 – 1 8 , 2 0 1 0 H e a d t o T o 29th Annual Morton A. Bosniak e I m a g i n g C o n f e r e n c e Refund Policy Please Print Clearly
First Name Last Name Address___ City ______ State _____ Day Phone Fax_______ Email_____ ____________ ____________ ____________ ____________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Zip ___________ ____________ ____________ ____________ _________________________________ ___________________________________ ___________________________________ ___________________________________
(must be provided for confirmation/receipt)
If you need to cancel your enrollment, a $75 service fee will be assessed for your tuition payment if written notice is received more than 30 days in advance and a $150 service fee for cancellations made within 30 days. No refunds are possible if written notification is not sent.
Course Cancellation Policy
In the unusual circumstance that this course is cancelled, two weeks notice will be provided and full tuition refunded. The NYU Post-Graduate Medical School is not responsible for any airfare, hotel or other costs incurred.
Methods of Payment
M Check in U.S. Dollars made payable to NYU Department of Radiology M Credit Card Payment (see below)
Sub-Specialty _____________________________________________ Dietary Restrictions________________________________________
Tuition Payment Options (Please Check)
Methods of Registration
M Mailing Form with Check or Credit Card Information M Faxing Form with Credit Card Information
Monday, Dec. 13 (Daily Fee) (Thoracic Imaging & Cardiac Imaging)
Tuesday, Dec. 14 (Daily Fee) (Musculoskeletal Imaging & Pediatric Imaging)
Tuesday, Dec. 14 Chelsea Art Tour (9:45-Noonish)
M $35 per ticket
Wednesday, Dec. 15 (Daily Fee) (Emergency Imaging & Interventional Radiology)
Thursday, Dec. 16(Daily Fee) (Neuroradiology & PET/CT Imaging)
Do not Fax form if registering online. Mail To
Marisa Bruno, NYU Department of Radiology 462 First Avenue, OBH, C&D, Floor 1, Room 4, New York, NY 10016
Fax To: (212) 263-3959 In Case of Questions, Contact:
Michelle R. Koplik, Director of CME Phone: (212) 263-3936 • email: firstname.lastname@example.org
or Marisa P. Bruno, Program Coordinator Phone:(212) 263-0724 • email: email@example.com
Payment by Credit Card
Card Member’s Name (print carefully)
Stop here if you are registering for the entire course———
Entire 5V Day Course
Thursday, Dec. 16 Chelsea Art Tour (9:45-Noonish)
M $35 per ticket
Card # ______________________________ _____________________
Friday, Dec. 17 (Daily Fee) (Abdominal Imaging & Breast Imag
Saturday, Dec 18 (Women’s Imaging)
( D a i l y F e e
Amount to be Charged: $
M American Express
Exp Date: Month/Year
_______ __ _____
Signature (required to process)
*Discounted Fees apply to: NYU School of Medicine alumni, M.D.’s employed by the Dept of Veterans Affairs, full-time active military personnel, technologists, retired physicians, current residents/fellows, Canadian and other non-U.S. physicians.
If you are registering on-line,you must fax a letter of authorization with the attendee’s full name and date registered to (212) 263-3959.Please state reason for using reduced fee.If you are mailing a registration form and check, please enclose the authorization letter at the same time.
Confirmation of Course Acceptance:
A confirmation will be sent to you by email if your email address is provided. Faxed confirmations are no longer possible.
If there is a specific question or topic relating to this course, please submit it on the registration form or on the website when registering online.
Reason for Discounted Fee: __________________________________
For Alumni(datesofyourNYUSOMorRadiologyTraining): __________________