CRS March Education Program - Thursday, March 26, 2020 Survey

1.ATTENDEE INFORMATION:

Attendee's Name:

Institution:

Address:

City, State, Zip:

Phone:

Fax:

Email:

2.Are you a member of the Chicago Radiological Society?

Yes

No

3.Please indicate your specialty:

Diagnostic Radiology

Radiation Oncology

Other (please specify)

4.Please indicate your meal choice:

Buffet Dinner

Kosher

By clicking the button below, you are submitting a reservation for the meeting. Please note: all reservations will be billed for whether or not you attend, as the Society is charged for all reserved meals. If you want this billed to a third party, please provide this information below.

5.Please provide billing information:(Required.)

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number: