Contact Information Payment Information

Contact Information
SNMMI Member # (if applicable):
First Name:
Last Name:
Professional Suffix:
Title:
Organization:
Mailing Address:
State:
City:
Zip:
Country:
Email Address (required):
Phone (please include country code):
Email
How did you hear about this event?
Postcard
Flyer
Facebook
SNMMI Website
Other:
Select Your Location:
Sioux Falls, SD | April 25, 2015
Syracuse, NY | August
Salt Lake City, UT | July 11, 2015
Wilkes Barre, PA | September
Portland, ME | August
Tucson, AZ | September
Select Your Registration Type:
Early-Bird Rate
Onsite Rate
SNMMI-TS Members
$25
$35
Non-Members
$40
$50
*The meeting will begin at 8:00 a.m. and conclude at noon. Attendees will receive 4 VOICE Credits. Attendees will receive a complimentary breakfast.
Payment Information
(Full payment is needed in order to process your registration)
Grand Total:_____________
Check: Please make payable to “Society of Nuclear Medicine & Molecular Imaging - Chapter Roadshow” (in US Dollars)
American Express
Mastercard
VISA
Name as it appears on card:
Amelia O’Brien
SNMMI Meetings &
Registration Manager
1850 Samuel Morse Dr.
Reston, VA 20190
[email protected]
Fax: 703.709.9274
Last four digits of credit card:
Expiration date:
Signature:
Today’s date:
(please add full credit card # below the dotted line)
Mail or Fax Form to:
Questions?
Call 703.652.6789
CANCELLATION/REFUND POLICY: Registration fees can be refunded only if a written cancellation request is received prior to 5:00 p.m. ET, three days before the start
of the event. Only cancellations made by mail, email or fax, and received before 5:00 p.m. ET, three days before the start of the event will be honored. However, you may
substitute one registrant for another at any time. All refunds will be issued within four weeks after the meeting. SNMMI is not liable for cancellation fees charged by hotels,
airlines or other means of transportation. To cancel, send written notification before 5:00 p.m. ET, three days before the start of the selected event to [email protected].
Please enter full credit card number: