MRI/CT Student Registration Form

MRI/CT Registry Prep Course Registration Form
Name *

First Name Last Name
SELECT REGISTRY PREP COURSE: *

MRI 21-10/ October 4 to December 15 (12 sessions: Mondays and Wednesdays) CT 21-10/ October 5 to December 7 (10 sessions: 9 Tuesdays and 1 Thursday session)
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Primary Phone #: *
Please enter a valid phone number.
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

By signing below, I attest that the above information is true to the best of my knowledge.
Signature

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MRI/CT Registry Prep Course Registration Form