REGISTRATION FORM - Workshop on Flow and Motion:  Imaging Assessment of Cardiovascular and Tissue Mechanics

1. REGISTRATION INFORMATION (Early registration is recommended) 
Name________________________________________________________________
Address______________________________________________________________
City_________________________________________________________________ 
State______________________________ Zip______________________________
Country______________________________________________________________
Phone (______)_____________________ Fax (____)________________________
E-mail________________________________________________________________
2. FEES (Includes Registration and Syllabus)
EARLY LATE/ONSITE
ISMRM Member US$450 US$550
Nonmember US$600 US$700

ISMRM Student*/Technologist Member

 US$200 US$200

Student/Technologist Nonmember*

 US$250 US$250
*Includes Interns, Residents, and Postdoctoral Fellows
When registering, nonmember students and postdocs must present a letter verifying their status.
Early registration must be received by Tuesday, 13 June 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