LOS ANGELES RADIOLOGICAL SOCIETY

Ultrasound Section Dinner Meeting
 

DO NOT EMAIL PAYMENT INFORMATION.  
Complete this form, print it and fax or mail to
LARS, PO Box 93125, Pasadena, CA 91109 - Fax: 626-836-6606
Select Registration Category
Select Conference Date
First Name
Middle Initial
Last Name
Credential: MD, RDMS, etc
Company
Your name and Company will appear on your event badge exactly as they appear here.
Address
Address
City
State
Zip Code
Home Address  Work Address
Email Address
Method of Payment Credit Card       Check  
Credit Card Number   Three digit security code 
Expiration Date    Billing zip code 
Check Number
Total - If you have a discount tuition voucher subtract $10 from tuition total.