RegiSTRaTion FoRm

ThRee eaSy WayS To RegiSTeR1 ONLiNe: www.asnc.org/asnc2012

2 FAx:* (301) 215 - 7113 Credit card payments only

3 MAiL:* ASNC 4340 East West Highway Suite 1120 Bethesda, MD 20814-4578

NAME W/DEgrEE(S)

INStItutIoN

ADDrESS

CIty/StAtE/ZIp/CouNtry

pHoNE/FAx/E-MAIl

meThod oF PaymenT CHECk AMEx MAStErCArD VISA

CArD # Exp. DAtE CVC/SECurIty CoDE

prINt NAME oN CArD SIgNAturE

Make check payable to ASNC in U.S. funds

Join noW! Visit aSnC’s member Center at www.asnc.org and complete the membership application or call (301) 215-7575.

eaRly BiRd RegiSTRaTion (By July 1, 2012)

PRe-RegiSTRaTion (July 2 – august 17, 2012)

SPeCial oFFeRS (Select Syllabus information below.) member non-member member non-member

ASNC2012 PLuS Board Exam prep Ancillary program $865 $1095 $965 $1195

ASNC2012 PLuS Nuclear Cardiology for the Working technologist program $425 $500 $525 $600

aSnC2012 RegiSTRaTion

physician $535 $785 $635 $885

technologist $295 $395 $345 $445

Nurse $295 $395 $345 $445

practice Administrator $295 $395 $345 $445

Abstract presenter $295 $395 $345 $445

Abstract presenter (Fellow-in-training w/verification letter) $0 $0 $0 $0

other (please check appropriate category) $295 $395 $345 $445

Scientist (non-MD or equivalent) Industry (non-MDs) physician-in-training (Affiliate) physician (Active Duty Military with Documentation) other

anCillaRy PRogRamS (Select Syllabus information below.)

Board Exam preparation Course (9/4-9/6) $765 $995 $865 $1095

Nuclear Cardiology for the Working technologist (9/5-9/6) $325 $400 $425 $500

BoaRd exam PRePaRaTion aTTendeeS:

Syllabus Selection: please select one syllabus option. Note that all Board exam Preparation registrants will have access to the electronic syllabus.

Electronic Syllabus: $0 Black-and-White printed Syllabus: $60 Color printed Syllabus: $225

totAl:

$———

nuCleaR CaRdiology FoR The WoRking TeChnologiST aTTendeeS:

Syllabus Selection: please select one syllabus option. Note that all Working Technologist registrants will have access to the electronic syllabus.

Electronic Syllabus: $0 Black-and-White printed Syllabus: $30 Color printed Syllabus: $135

totAl:

$———

SuBToTal $

aSnC oFF-SiTe eVenT BalTimoRe oRioleS VS. neW yoRk yankeeS aT Camden yaRdSTicket price includes dinner at Camden yards and ticket to the game

Saturday September 8, 2012, 5:30 p.m. –10:30 p.m. $75 per ticket ———— Number of ticketstotAl:

$———

ToTal PaymenT $

aSnC2012 meeTing on demand

this is your opportunity to have all of the valuable meeting content available to you after the meeting has ended at 25% off the on-site purchase price. $75

totAl:

$———

SuBToTal $

The 17th annual Scientific Session of the american Society of nuclear Cardiology

(Must be a current member to qualify for member pricing — check the box below and join today for no additional charge.)

AAAAAAAAASSSSSNCNNNNCCCCBALTIMORE20122012AAAAAASSSSSSSNNNNNNNCCCCCCCCCAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC

AAAAAAAAASSSSSNCNNNNCCCCBALTIMORE20122012AAAAAASSSSSSSNNNNNNNCCCCCCCCCAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC

*An extra fee of $25 will be charged to mail or fax registrations.