SymposiumRegistrationForm-VanderbiltUniversityMedical.docVIP

Symposium Registration 39th Annual Diagnostic Sonography Symposium Vanderbilt University School of Medicine Department of Radiology and Radiological Sciences Embassy Suites Nashville South-Cool Springs 820 Crescent Centre Drive │ Franklin, Tennessee 37067 July 18-19, 2015 * Required information. ** Your registration confirmation and CME credits will be sent by e-mail. Please provide requested e-mail address to receive both. CONTACT INFORMATION (Please print clearly) Name* Degrees/Title Company/Affiliation Mailing Address (1)* Mailing Address (2) City/State/Zip* Telephone(s)* E-Mail** Registration type* (please check appropriate boxes) NON-VANDERBILT UNIVERSITY MEDICAL CENTER □ Physicians: (received on or before July 1, 2015) $390.00 (after July 1, 2015) $440.00 □ Sonographers: (received on or before July 1, 2015) $200.00 (after July 1, 2015) $250.00 □ Sonography Students Only: $ 75.00 VANDERBILT UNIVERSITY MEDICAL CENTER □ Vanderbilt Physicians: $100.00 □ Vanderbilt Residents: $ 75.00 □ Vanderbilt Sonographers Sonography Students: $ 50.00 payment Make check payable to Vanderbilt Radiology/Symposium Please return completed registration form along with check to: Vanderbilt University Medical Center Department of Radiology Attn: Sonography Symposium Vera Merriweather CCC-1121 MCN 1161 21st Avenue, S Nashville, TN 37232-2675