AIRP 2017 Registration Form
Fields marked with * are mandatory.
Family Name
Your answer
First Name
Your answer
SPRMN Membership number
Your answer
Participant
Address
Your answer
City
Your answer
Zip Code
Your answer
Country
Your answer
Hospital
Your answer
Department
Your answer
Cell Phone
Your answer
Fax
Your answer
Email
Your answer
Participant - Before May 21
SPRMN Full Member - Before May 21
SERAM, SPR, CBR Full Member
SPRMN Member in-training - Before May 21
Non-Members SPRMN - Before May 21
Radiographers - Before May 21
Participant - After May 21
SPRMN Full Member - After May 21
SERAM, SPR, CBR Full Member
SPRMN Member in-training - After May 21
Non-Members SPRMN - After May 21
Radiographers - After May 21
Payment
Payment Type
Required
Check Number
Your answer
Bank Transfer Confirmation
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