COURSE REGISTRATION FORM

(Please type or print clearly.)

Course Title(s) and Number(s) Desired_________________________________________________

__________________________________________________________________________________

Attendance Dates___________________________________________________________________

Name_____________________________________ MD RN LPN RT RDMS RDCS RVT Other (Circle one)

Sonographer/Specialist: College/Technical School________________________________________

Date of Graduation__________________Experience_______________________________________

Specialty________________________Current Position_____________________________________

Following address is: Business_____ Home_____

Address__________________________________________________________________________

City_______________________________________________State____________Zip____________

Daytime Telephone (_______)_________________________

Amount Enclosed $________________(U.S. Funds)

Make checks payable to: BOWMAN GRAY SCHOOL OF MEDICINE - ULTRASOUND
If paying by credit card, please complete:

VISA____ MasterCard____

Credit Card #_____________________________________Expiration Date____________________

Signature__________________________________________________________________________

For further information, please call 910-716-4505 or 800-277-7654. FAX 910-716-4204 (http://www.bgsm.edu/bgsm/ultrasound)
(Photocopies of this form are acceptable.)

Mail to:

If you have a disability which requires special accommodations, advise us of your needs at least three weeks in advance of the course.