Registration Form: 
45 Hour NMT Review: Nuclear Medicine Seminar

Please SUBMIT this entire form no matter which payment plan you choose to ensure a complete registration.

I wish to use a Credit Card- 
Submitting my payment with secure transmission using Paypal.com. If you do not have a paypal account, you can simply click on the check out links to use credit cards at that site. 

No, I will send you a check for $1000

Registration: 45-hour Nuclear Medicine Review Course

Please complete this registration form.
Please supply your VOICE #, NMTCB#, ARRT #, or State License # to insure receipt of CE Credit. This number will be printed on the certificate presented to you at the conclusion of the course.

Name:  
Address:
City:     
State:       Zip Code:
Email Address              
Hospital or Clinic          
Daytime Phone or Pager
Work Fax                     
Special Notes               

VOICE #, NMTCB#,
ARRT# or State License #           Required ONLY if CE Credit is desired for this seminar

Please List the Seminar You Are Registering For...     

I learned about this course:
Flyer in Mail
A Colleague
Website

To ensure a prompt processing of your registration,
please enter the security code below:

Security Code: 

Please enter security code:

For Additional Information: 
Please Contact Stephen M. Karesh,  Course Director at...

Consultants in Nuclear Medicine
2910 W. Estes Ave 
Chicago, IL 60645
Phone:
(773) 802-7617    
FAX: 
(773) 304-2545  
E-mail: nucmedconsultants@comcast.net