CE for RTs & GXMOs
Registration Form
February 23, 2008

Print the form below then type or print all required information. *Confirmations will be sent to e-mail addresses only.

NAME  ________________________________

_________________________________
STREET ADDRESS            CITY        STATE           ZIP CODE

 ____________________________________________
 AREA CODE          DAYTIME PHONE NUMBER

*___________________________________
E-MAIL ADDRESS

For those employed in private practice offices, please supply the following:

OFFICE NAME:____________________________________

____________________________________________
STREET ADDRESS        CITY               STATE          ZIP CODE

___________________________________________________
AREA CODE                                  PHONE NUMBER

Check below:
____ Pre-registrered OSRT Member ($95)
____ Pre-registered Non-OSRT Member ($155) (includes membership, please submit member application with fees)
____ Onsite Registration (add $25.00)
Preregistration Deadline: February 13, 2008

Method of Payment: Check one:
Check or money order:_____ Amount Enclosed: $_________

Credit Card: _____MasterCard  ____ Visa
Credit Card account #: _________________________________
Expiration Date on Card:_________
Name on Card:________________________________________
Amount to be charged: _______

Make check or money order to OSRT.  Mail to:
Emilee Palmer BS., RT(R)(CT)
OSRT CPE Committee Co-Chair
545 Raccoon Lane
Sunbury, Ohio 43074
Toll Free Phone (866) 405-OSRT (6778)

CE events are subject to cancellation if unforeseen situations arise or if the number of pre-registered attendees is less than10. A full refund would be given in the event of cancellation.