Please return this form to: Maria E. Matias, Radiology Department

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I wish to register for the New Jersey Medical School-Department of Radiology's
CORE BOARD REVIEW COURSE which will take place from
 Monday – Friday May 11 – 15, 2015
Registration Fee: $895 for the first 100 registrants and $1000 for the next 50
(non-refundable, non-transferable) and does not include hotel costs
Please return this form to: Maria E. Lopez, Radiology Department, UMDNJ- New Jersey Medical
School, 150 Bergen St. UH C 318 A, Newark, NJ 07101-1709 with a check or money order made
payable to: * NJMS – Radiology. Do not send cash.
Deposit of $100 (non-refundable, non-transferable) is due in order to hold a spot.
Registration balance is due no later than February 15, 2015
With a check or money order made payable to: *NJMS – Radiology. Do not send cash.
PLEASE PRINT OR TYPE INFORMATION
Amount of payment enclosed $____________
Balance $__________
Name: ________________________________________
Home Address: _________________________________
City: ____________ State: _____________ Zip: _________
Institution affiliation: ____________________________________
Cell phone including area code: _______________________ Home number: ________________
E-mail address used most often: (No hotmail accounts) ______________________________
Do you have special dietary needs? Yes _____ No _____
If yes please specify __________________________________________________
If you have any questions, please email me at [email protected] or call 973-972-6025
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