Texas Society of Radiologic Technologists, Inc

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Registration Form

TSRT 2010 ANNUAL MEETING REGISTRATION FORM

Brookhaven College     3939 Valley View Lane, Farmers Branch, Dallas, TX 75244

FULL NAME                                                                                                                                                    

ADDRESS                                                                                                                                                       

CITY, STATE, ZIP CODE                                                                                                                                

EMPLOYER OR SCHOOL                                                                                                                               

DAY PHONE                             EVENING PHONE                                 EMAIL ____________________

PROFESSIONAL CREDINTAL STATUS __________________DATE OF BIRTH _______________

TO REGISTER:  MAIL REGISTRATION FORM TO: TSRT - 806 WOODLAWN  KILGORE, TEXAS 75662   Fax: 903-986-8489

 

ANNUAL MEETING SCHEDULE:  Please consult the TSRT Website for complete information regarding the 2010 Annual Meeting Schedule and Meeting Agendas at TSRT.INFO  Email questions to tsrt@runbox.com

 

CANCELLATION POLICY: A request for refunds for pre-registration must be made in writing and postmarked on or before February 15, 2010.  A cancellation fee of $ 100.00 will be deducted from the refund. 

 

DEADLINES:  Pre-Registration is due by February 15, 2010.

 

ETHNICITY INFORMATION is used to meet Texas State reporting requirements and providing this infomation is voluntary on your part.

_____White, Non-Hispanic     _____Hispanic American     _____Indian/Alaskan Native     _____ Other     _____Black, Non-Hispanic     _____Asian/Pacific Islander     _____International/Non-Immigrant     _____No Response

 

REGISTRATION FEES:  All Non-Member Registration Fees include a membership for one year with TSRT.

 

REGISTRATION RATES AND CATEGORIES
 

                                                                                     Pre-Registration      On-Site

Complete Program RT (TSRT Member)                       $225.00               $250.00

Complete Program RT (Non-Member)                        $275.00               $300.00

Complete Program Student (TSRT Member)             $  85.00               $100.00

Complete Program Student (Non-Member)              $100.00               $125.00

One Day RT (TSRT Member) __Friday __Saturday   $  85.00               $100.00

One Day RT (Non-Member) __Friday __Saturday    $100.00               $125.00 

Box Lunch     __Friday($10) __Saturday($10)         $  20.00

BBQ Dinner on Friday                                                     $  15.00

Cowboy Stadium                                                            $15.00                                                                                                                       

 

Payment:  Checks, money order, cashier’s check, or credit card information must accompany all registration forms.  No purchase orders will be accepted.  If you cannot send full payment postmarked by February 15, 2010, you are required to pay on-site rates.  Make checks, money order, or cashier’s check payable to TSRT.

 

Credit Cards: Charge my MasterCard, Visa, or Discover Card _________________________________

 

Expiration Date (M/Y): ________ Security Code:______Signature: ____________________________