TECHNOLOGIST REGISTRATION FORM
ARKANSAS SOCIETY OF RADIOLOGIC TECHNOLOGISTS
60th STATE CONVENTION
EMBASSY SUITES, ROGERS, ARKANSAS
NAME _____________________________________________
ArSRT Member Number_______________ (This is not your state
license number)
ADDRESS _______________________________________________________________
City, State,
Zip______________________________________________________________________
HOME PHONE _________________________E-MAIL_________________________________
PRE-REGISTRATION DEADLINE: POSTMARKED BY
REGISTERED & LICENSED TECHNOLOGISTS: Please CIRCLE desired registration
days
Thursday
ONLY $50.00
Friday ONLY (Lunch
Included) $75.00
Saturday ONLY (Lunch
Included) $75.00
TWO DAY REGISTRATION
Thursday
& Friday (Friday Lunch Included) $95.00
Friday & Saturday
(Lunches Included) $110.00
THREE DAY REGISTRATION
Thursday, Friday
&Saturday (Fri. & Sat. Lunches Included) $129.00
LUNCH RESERVATIONS (required to guarantee meal)
I plan on attending
the: ____ Honors Luncheon,
_____President’s Luncheon,
____Extra Lunch tickets may be purchased for
25.00 each. ______Fri.
______Sat.
_____________________________________________________________________________
MAKE CHECKS PAYABLE TO ArSRT
& MAIL WITH REGISTRATION FORM TO: ArSRT, PO BOX
241492, LITTLE ROCK, AR 72223
ALL PARTICIPANTS MUST BE MEMBERS OF THE ArSRT BY
NO REFUNDS. EXTENUATING CIRCUMSTANCES MUST
BE WRITTEN AND POSTMARKED TO THE ArSRT BY