MRI/CT Student Registration Form

MRI/CT Registry Prep Course Registration Form
Name*

First NameLast Name
MRI 22-09/ Begins September 12, 2022 (12 sessions: Mondays & some Wednesdays at 5:30PM)CT 22-09/ Begins September 15, 2022 (10 sessions: Thursdays at 5:30PM)
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Primary Phone #:*
Please enter a valid phone number.Format: (000) 000-0000.
ARRT ID #
ARDMS ID#
NMTCB ID#
New York State DOH License #

PAYMENT ($100 Non-Refundable Registration Fee)

REGISTRY PREP COURSE REGISTRATION

non-refundable registration fee

$100.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

By signing below, I attest that the above information is true to the best of my knowledge.
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MRI/CT Registry Prep Course Registration Form