MEETING REGISTRATION AND HOTEL RESERVATION FORM

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					                                  MEETING REGISTRATION AND HOTEL RESERVATION FORM




          “NEUROIMAGING OF MS: STATE-OF-THE-ART AND FUTURE DIRECTIONS” CONFERENCE
                NOVEMBER 7 – 8, 2009, L’ENFANT PLAZA HOTEL, WASHINGTON, DC
           EXTENDED ADVANCE REGISTRATION DEADLINE & HOUSING DEADLINE IS FRIDAY, OCTOBER 2, 2009.
I. MEETING REGISTRATION : (Please Print or Type)
________________________________________________                                                  _____________________________________________
First Name, Initial, Last Name, Degree                                                             (Printed Name for badge)
________________________________________________                                                  (_________)___________________________________
Address                                                                                           Daytime Telephone Number
________________________________________________                                                  (_________)___________________________________
Address                                                                                           Fax Number
_______________________________________ __________________                                        ______________________________________________________
City, State, Country                                         Zip Code/Postal Code                 Email Address

Please indicate appropriate meeting registration fees below: (U.S. Funds Only)
Standard Registration Fee              $ 300      _____________
Fellow Reduced Registration Fee        $ 200      _____________
Program Faculty                                  Complimentary                 Form of Payment:  Check/Money Order (payable to NER Foundation)
                   TOTAL REGISTRATION $_____________                            VISA      MasterCard     American Express

 _______________________________                     __________________                           _____________________________________________________
 Credit Card Number                                  Expiration Date                              Authorized Signature

                                                                                                  __________________________________________________________________
                                                                                                  Printed Name on Card

Please indicate any special dietary needs:  Kosher               Vegetarian          Other _____________________________________________________________
        Please check here if you have any special needs/disabilities and a representative will contact you.


II. SOCIAL EVENT REGISTRATION:
Are you planning to attend the Saturday, November 7, 2009 Dinner/Lecture: _____ Yes                     _____ No

III. HOTEL RESERVATIONS:
Extended Housing Deadline is Friday, October 2, 2009. Housing requests can only be accommodated if received by this date, or until room block has been filled.
Room type is subject to availability. Room rates are subject to an approximate 14.5% tax.
             NO HOTEL RESERVATION IS NEEDED

ROOM TYPE:              (STANDARD ROOM)
 Single/Double Occupancy--$209 (approximately $240 with taxes) PER NIGHT        I require a smoking room
 Triple Occupancy -- $229 (approximately $262 with taxes) PER NIGHT  Quad Occupancy--$249 (approximately $285 with taxes) PER NIGHT
 Arrival Date: _________________________________________ Departure Date: ________________________________________________
All reservations MUST be guaranteed by a major credit card for first night’s lodging.
 VISA                   MasterCard                          American Express                    Check (Payable to NER Foundation)

_________________________________________                          ____________                 ______________________________________________________
Credit Card Number                                                  Expiration Date             Signature

____________________________________________________________
Printed Name on Card
Meeting Registration Cancellation Policy: Cancellations received after September 18, 2009 will receive NO REFUND.

FAX/MAIL COMPLETED FORM TO: NEURORADIOLOGY EDUCATION AND RESEARCH FOUNDATION (NERF)
                                             2210 MIDWEST ROAD, SUITE 207
                                              OAK BROOK, IL 60523-8205
             Phone: 1-888-734-7300 or 630-574-1376  Fax: 630-574-1740  Email: ltannehill@asnr.org