Coronary CTA Course Registration

Complete the following registration form to reserve a space in a course. Your reservation will be confimed after your payment is received.

All fields denoted with an asterisk (*) are required.

Registration Information

Course*

Course Version*

Physician
Technologist

First Name*

Last Name*

Degree/License/Title*

Institution*

Specialty*

Workstation Used at Facility *

e.g. GE, Vital Images

Address Line 1*

Address Line 2

City*

State*

Postal Code*

Email Address*

Email Verification (type email again)*

Telephone Number*

- - x

Fax Number

- -

Special Dietary Needs (i.e. Kosher Meal)

Other Special Needs (i.e. Wheelchair Access)

Payment Method* (not required for waiting list)

Credit Card Payment Via Telephone
Check
Secure On-Line Credit Card Payment (provide card info here)

Card Number:
Expiration Date:
Card Code**:
Note: For the physician course, $2300 will be charged; for the technologist course, $800 will be charged. ** On VISA, Mastercard and Discover cards, the card code is the last 3-digit number in the signature window on the back of the card. On American Express cards, the code is a 4-digit number printed on the front of the card above the credit card number.

If paying by credit card, the payment may take a few seconds to process. ONLY CLICK THE REGISTER BUTTON ONCE.