ENROLLMENT APPLICATION FOR SMRT NORTHWEST REGIONAL SEMINAR

Name:_________________________________________________

Address: ______________________________________________

City: ___________________ State: ____________ Zip: _________

Phone: _____________________ Fax: _______________

e-mail: __________________________________

Seminar Registration Indicate fee
	Early	Late/On Site
SMRT Member Fee	___ $40	___ $50
Nonmember	___$75	___$85
*Nonmember	___$110	___$120
*with payment of $110(early) or $120(late/on site), $70 will be applied to 1997 SMRT membership fee.

Cancellation Policy
All cancellation requests must be in writing. Cancellations must be received in writing before January 15, 1997 for a full refund. No refund will be available subsequent to january 15, 1997, or for persons who do not attend the seminar.

You may register by mail, phone, or fax with your credit card

Charge fees to my:	___Visa	___ Mastercard	___ Eurocard
Card Number: ___________________________
Expiration date: _________________________
Payment Amount: ________________________
Please note: Fees include coffe breaks, refreshments, and lunch.
SIGNATURE: ______________________________

Register by Mail to:
SMRT/ISMRM
PO Box 45690
San Francisco, CA 94145-0690
make checks payable to SMRT. Fees are in US$ and must be paid in US$.


Registration information:
Telephone: (510) 841-1899, Fax (510) 841-2340
e-mail: info@ismrm.org

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