Annual Meeting Registration Form

American College of Nuclear Medicine
February 23- 25, 2007- Wyndham New Orleans at Canal Place - New Orleans, Louisiana
 Please return registration form before January 25, 2007.
(All Badges and programs are to be picked up at the ACNM Registration Desk.)

NAME  ___________________________________________
(with MD, PhD, etc.) as you wish printed on badge
HOME ADDRESS  ___________________________________________
CITY  ___________________________________________
STATE  _____________________  ZIP CODE _______________
 
HOSPITAL  ___________________________________________
HOSPITAL ADDRESS  ___________________________________________
CITY  ___________________________________________
STATE  _____________________  ZIP CODE _______________
HOSPITAL PHONE  ___________________________________________
HOSPITAL FAX  ___________________________________________
(        ) My companion/Spouse will accompany me.
NAME  ___________________________________________
(Companion/Spouse name you wish printed on badge)

REGISTRATION FEE:

ACNM Meeting Registration
            (ACNM Member and 1 Guest) 		$395.00
ACNM Meeting Registration  
            (ACNM Member and Single Registration) 		$345.00
Residents and Fellows $100.00
Student Technologists No Charge
  
Non-Member & 1 Guest Registration  
 		$475.00
Non-Member Single Registration  
 		$425.00
 
Technologists $100.00
 

TO REGISTER: Mail your completed registration form along with your check payable to:
AMERICAN COLLEGE OF NUCLEAR MEDICINE
101 WEST BROAD STREET, SUITE 614
HAZLETON, PA 18201
Phone: (570) 501-9661 FAX: (570) 450-0863
Website: www.acnucmed.org

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