REGISTRATION FORM - Workshop on MR of Cancer:  Frontiers in Metabolic, Molecular and Clinical Imaging
1. REGISTRATION INFORMATION (Early registration is recommended) 
Name________________________________________________________________
Address______________________________________________________________
City_________________________________________________________________ 
State______________________________ Zip______________________________
Country______________________________________________________________
Phone (______)_____________________ Fax (____)________________________
E-mail________________________________________________________________
2. FEES Includes Registration, 3 nights' accommodation (13th, 14th and 15th of October), dinner on the 13th, all three meals on the 14th and 15th, breakfast on the 16th of October,  and Syllabus.
EARLY LATE/ONSITE
ISMRM Member US$850 US$950
Nonmember US$1,000 US$1,100

ISMRM Student*/Technologist Member

 US$700 US$700

Student/Technologist Nonmember*

 US$800 US$800
Additional Night (Add US$149 per    night, includes breakfast, dinner, standard recreation and unlimited golf green fees) US$149
 		 US$149
Bringing a Guest (add'l fees required).
You will be contacted by ISMRM office before processing payment to discuss fees.		      
*Includes Interns, Residents, and Postdoctoral Fellows
When registering, nonmember students and postdocs must present a letter verifying their status.
REQUIRED OF ALL REGISTRANTS:
Please provide your anticipated arrival and departure dates:
Arrival:                                                        Departure:
Early registration must be received by Friday, 1 September 2006.
3. PAYMENT OPTIONS
You may register by mail, phone, or fax with your credit card.
Charge fee to my Visa MasterCard American Express

Card_number:________________________________________________________

Expiration_date:______________________________________________________

Cardholder_name:_____________________________________________________

Payment_amount:_____________________________________________________

Signature:__________________________________________________________ 
REGISTER BY MAIL TO:   
ISMRM, P.O. Box 45690, San Francisco, CA 94145-0690 U.S.A.  
Make checks payable to ISMRM. Fees are in US$ and must be paid in US$.

REGISTRATION INFORMATION:
Telephone: +1 (510) 841-1899; Fax: +1 (510) 841-2340; E-mail: info@ismrm.org; Web site: http://www.ismrm.org