Basic Interpretation of MRI Imaging 90-Minute Webinar January 31, 2023

First Name:*
Middle Initial:
Last Name and Credentials:*
Organization:
Address:*
City:*
State:*
Zip:*
Phone:*
Cell:
Fax:
E-mail:*
Please answer all of the following questions:
----------------------------------------------------------------------
Medical Degree:*

MDDOPhD
----------------------------------------------------------------------
Primary professional practice setting (please check all that apply):

Ambulatory SurgeryHospitalOffice PracticeAcademicUniversityAdministrativeMilitaryVA
----------------------------------------------------------------------
Payment Information

Webinar - Live $225.00

Add-on Review Course Recording$25.00

Resident/Fellow Discounted Rate$25.00

Proof of current resident or fellow status must be received before registration can be activated. Please send letter or documentation to crogers@asipp.org

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

CANCELLATION POLICY:
Please enter the letters to the right before submitting form:*
ASIPP reserves the right to cancel this course upon reasonable notice and will assume no financial obligation to registrants for cancellation for reasons beyond its control; however, registration fees would be refunded.

Virtual meeting registrations cannot be refunded after registration has been activated.
Email
example@example.com
Heading
Should be Empty:

Heading