CVI’s 10th Anniversary Update in Nuclear Cardiology

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CVI’s 10th Anniversary Update in Nuclear Cardiology

  1. 1. CVI’s 10th Annual Update in Nuclear Cardiology Tuesday, February 18, 2014 REGISTRATION FORM Registration Fees Be an early bird … sign up and pay your registration by Jan. 20, 2014 and take $35 off your registration fee! Name _______________________________________________________________ Degree _____________________________________________ Gender J M JF Clinical Position ________________________________________________________ • Physicians and Industry: $385 ($350 early bird by 1/20/14)** • Technologist, Mid Level Provider, Nurse: $210 ($175 early bird by 1/20/14)** • Fellows, Residents, Medical Students: $160 ($125 early bird by 1/20/14)** Clinical Affiliation Name __________________________________________________ **Price reflects discount of $10 for payment by cash/check. Please add $10 for Visa/MC/AMEX. City ________________________________________ State _________ Zip ________ Syllabus Several days prior to the program, syllabus including presentations will be available for download from a secure website. At registration you will receive a USB storage device with the same information at no additional charge. At the conference, neither printers nor electrical outlets are available for attendee use. Hard copy black & white syllabus including presentations may be ordered in advance for $50, and available at registration. Hard copy syllabi must be ordered by February 10, 2014. Additional printed syllabi not available onsite. Faculty PowerPoint presentation handouts are for the use of course attendees only pre and post-conference. This material may not be used, shared or distributed electronically. **FREE Apple iPad 2 Drawing Details In order to be entered into the FREE Apple iPad 2 Drawing, you must: • Register and pay for CVI’s 10th Annual Update in Nuclear Cardiology by 5:00pm EST on Monday, January 20, 2014 • Submit your fully completed online program evaluation for CVI’s 10th Annual Update in Nuclear Cardiology by 5:00pm EST on Monday, March 10, 2014 • And you are entered to win… It’s as easy as that! Winner will be contacted via email. Phone ______________________________________ Fax ______________________ Email Address__________________________________________________________ Mailing Address ________________________________________________________ _____________________________________________________________________ Is this address work? __________________________ Home? ______ Other? ______ Dinner Selection: J Chicken J Fish J Vegetarian Important Notes: You MUST register by January 31, 2014 to guarantee your seat. Register online at www.cviphiladelphia.org Please make checks payable to: Cardiovascular Institute of Philadelphia P.O. Box 56598 • Philadelphia, PA 19111 Phone: 215-389-2300 • Fax: 215-389-5450 Course Registration Cancellation Policy: Requests in writing for refunds less $35 administrative fee by January 31, 2014, processed after the meeting. Registrations are transferable with prior notification to CVI by February 10, 2014. Order Early Bird Discount Regular Price Total Physicians & Industry Registration ____ @ $350 (by 1/20/14) ____ @ $385 (after 1/20/14) $ ________ Technologist, Mid Level Provider, Nurse Registration ____ @ $175 (by 1/20/14) ____ @ $210 (after 1/20/14) $ ________ Fellows, Residents, Medical Students ____ @ $125 (by 1/20/14) ____ @ $160 (by 1/20/14) $ ________ Hard Copy Syllabus Must order by March 13, 2013 N/A ____ @ $50 Pay by Visa/MC/Amex Add $10 per registration Apple iPad 2 Drawing Entry** FREE Grand Total J Visa J MC $ ________ Add $10 per registration $ ________ FREE $ ________ J Amex Card # _______________________________________________________ Exp. Date ___ /___ Name as appears on card ________________________________________________________ Billing address of card ___________________________________________________________ _____________________________________________________________________________ Signature ______________________________________________________________________

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