GEORGIA SOCIETY OF RADIOLOGIC TECHNOLOGISTS, INC.
60th Annual Meeting � April 23 �26, 2010
Lake Blackshear Resort & Golf
Cordele, GA

PRE-REGISTRATION FORM

GEORGIA SOCIETY OF RADIOLOGIC TECHNOLOGISTS, INC.
PO Box 767369 ─ Roswell, Georgia 30076-7369

Telephone: 1-888-314-1100 or 770-475-5216

Fax: 770-475-5218

This form must be submitted by April 17,2010. **
After these deadline dates, participants must register on-site. There will be an additional $10.00 fee for on-site registration.

  Technologist Member* Technologist Non-Member Student Member Student Non-Member Guest Pass**
Registration Fee � 3 days $200 $250 $85 $100 $85
Daily Rate $90 $110 $75 $90 --

*Registration includes: All educational sessions, business sessions, continental breakfasts, lunch and evening social functions (if provided).
* If proof of out of state membership provided, registration fee will be the same as a GSRT, Inc. member.

NOTE: Non-members may take advantage of the member registration rate by including GSRT, Inc. membership dues of $35.00 along with member pre-registration fee.

SPECIAL PROMOTION: Non-members, who pre-register by February 28, 2010, can join GSRT, Inc for the remainder of 2009-2010 society year for RT rate of $15.00 or Student rate of $8.00.

GSRT, Inc is offering each attendee the opportunity to pre-order a T-Shirt to wear for the meeting at cost of $15.00 per shirt.

Pre-orders and pre-paid only, please! Please list number of shirts and sizes below!

Contact Information
Full Name:
Credentials: (Example: RT (R)(CT) etc.)
Phone: (Please include your Area Code)
Work Phone: (Please include your Area Code)
E-Mail:
Work Modality:
Address:
 
City:
State:
Zip Code:
 
Credit Card Billing Information (Check to use Contact Information: )
Full Name:
Phone: (Please include your Area Code)
E-Mail:
Work Modality:
Address:
 
City:
State:
Zip Code:
   
Credit Card Number  
Expiration Date:
Card Type MasterCard Visa Discover
 

Registration Fees - Payments are non- refundable

Registration Type  
$200 Technologist Member - 3 Day Event
$250 Technologist Non-Member - 3 Day Event
$85 Student Member - 3 Day Event
$100 Student Non-Member - 3 Day Event
$85 Guest Pass - 3 Day Event
Daily Registration Type  
$90 Technologist Member - Saturday Only
$90 Technologist Member - Sunday Only
$90 Technologist Member - Monday Only
$110 Technologist Non-Member - Saturday Only
$110 Technologist Non-Member - Sunday Only
$110 Technologist Non-Member - Monday Only
$75 Student Member - Saturday Only
$75 Student Member - Sunday Only
$75 Student Member - Monday Only
$90 Student Non-Member - Saturday Only
$90 Student Non-Member - Sunday Only
$90 Student Non-Member - Monday Only
T-Shirt Special  
$15 Mens Small T-Shirt
$15 Mens Medium T-Shirt
$15 Mens Large T-Shirt
$15 Mens X-Large T-Shirt
$15 Mens 2X-Large T-Shirt
$15 Mens 3X-Large T-Shirt
$15 Ladies Small T-Shirt
$15 Ladies Medium T-Shirt
$15 Ladies Large T-Shirt
$15 Ladies X-Large T-Shirt
$15 Ladies 2X-Large T-Shirt
$15 Ladies 3X-Large T-Shirt
     
Price $
Please "Calculate" your membership fees before continuing.

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