Registration by Check
Registration Fee is $2000. Registration is limited to enhance the individualized attention from the faculty and hands-on experience, so please register as soon as possible.
Please complete the following information below and return by fax (917 - 432 - 2345) or e-mail firstname.lastname@example.org.
Last Name, First Name MI, Highest Degree:
Department (include box no).:
City State/Foreign Country Zip or Mail Code:
Daytime Phone (with area code):
Fax (with area code):
Where did you hear about us:
Please make check payable to:
fMRI Consultants LLC
For further information please contact:
Andrei Holodny, MD
Full refunds, less $200 administrative fee, will be granted to those providing written notification of withdrawal with at least 30 days notice. After that date, no refunds will be given.
If you have additional questions, don't hesitate to call (201) 767-1942.