Medical Imaging Continuing Education Event RSVP

Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City State ZIP Code
Please list your credentials.
Example: RDMS, RVT, RTR, (M), (CT), RT(T)
Registry Credential Number(s) (ARDMS, ARRT or CCI):
Food restrictions:
I am registering as a:*
- Attendee
- Current Bellin College Student
- Current Bellin College Clinical Preceptor
I will be attending this event:
- In Person
- Virtually (>100 miles from Bellin College)
Payment
Price:
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country