Basic MRI / Registry Review Registration Form

If you wish to register and pay online (uses PayPal), CLICK HERE
(If you plan to pay for more than one attendee
please do not pay online but rather fill out the form and send by fax)

Or

If you are going to register by US Mail or by Fax, Fill out the form below completely
Use the print function of your browser to print this form.
Send it along with your check
(if paying by check) to the address shown below.

If paying by credit card, you may fax the form to: 530.733.3097

Upon receipt of the registration form and tuition payment,
you will be sent a confirmation letter.
It is important that you provide a fax number and/or email for correspondence.

Be sure to check which program you would like to attend. Note that on some months, an optional day of cross-sectional anatomy is offered.

March 23 - 26, 2009 ($875)

April 27 - 30, 2009 (MR Principles Only - $875)

April 27 - May 1, 2009
(Sectional Anatomy AND 4-day MR program - $1000)

May 1, 2009
(Sectional Anatomy ONLY - $175)

June 8 - 11, 2009 ($875)

July 20 - 23, 2009 (MR Principles Only - $875)

July 20 - 24, 2009
(Sectional Anatomy AND 4-day MR program - $1000)

July 24, 2009
(Sectional Anatomy ONLY - $175)

Name:

Address:

City: State: Zip:

Telephone, Work (inc. area code):

Fax, Work (inc. area code):

Telephone, Home (inc. area code):

E-mail:

(providing an email or fax number will allow for a more rapid confirmation)

4-Day Basic MRI / Registry Review Tution: $875
5-Day program with Anatomy $1000
Anatomy only $175

Make Check Payable To: William Faulkner & Associates, LLC

Mail Check To:
William Faulkner & Associates, L.L.C.
9005 Jenny Lynn Drive
Chattanooga, TN 37421

Phone 423.894.7214
Fax: 530.733.3097

Credit Card Payment

Indicate the card used for payment
(VISA / MasterCard, American Express or Discover)

VISA

Mastercard

Discover

American Express

A Name of card holder: Expiration Date:

Amount to be charged in US Dollars $

Card #:

ID (Security Code):
the CID is a 3 or 4 digit number in addition to the card number
(located on the back - VISA/MC or front of the card for Am Exp)

Card holder signature: ______________________________

Credit Card Billing Address Information:
Please enter the billing address of the credit card above
(who/where does the bill come to).

Address 1

Address 2

City

State Zip

If paying by credit card, all of the above information must be provided before the registration can be confirmed.

*Cancellation Policy: Written notice of cancellation must be received 2 weeks prior to programs for refund (minus a $50 administrative charge).