AIMsymposium Individual Registration

Personal Information            * Denotes Required Fields

* First Name:
* Last Name (Surname, Family Name):
Degree: If Other:
* Physician or Non-Physician: Physician Non-Physician
Specialty: If Other:
Affiliation:
* Cleveland Clinic Employee? Yes No
* Address Type: Home Other
* Address:
* City:
* State/Province:
* Zip/Postal Code:
* Country:
* E-Mail:
A valid registrant's email address is required for
confirmation and CME Certification
Alternate E-Mail (Secretary/Assistant):
* Phone: U.S. Telephone: - - or
International Telephone:
Cell Phone: U.S. Cell Phone: - - or
International Cell Phone:
Fax: U.S. Fax: - - or
International Fax:
* What source did you use to find out information
   about the AIMsymposium?		 If Other:
* Are you a returning participant of the AIMsymposium? Yes No

Full Registration: Wednesday-Friday

Practicing Physicians $765
US and Canadian Radiology Fellows in Training *
        (Tuition provided through an Educational Grant by W.L. Gore & Associates, Inc.)
        * Letter of verification from Chief of Service must be faxed to (888) 418-7043.
 Complimentary
Non US Fellows in Training
       * Letter of verification from Chief of Service must be faxed to (888) 418-7043.
 $325
PhDs $325
Nurse Practitioners $325
Physician Assistants $325
Residents $325
Nurses $325
Technologists $325
Exhibitors (This fee applies to only those exhibiting at meeting) $575
Pavilion Holders (Discount Code Required) $575
Allied Health Care Professionals $850

Component Meetings: Wednesday Only

Wednesday Only - Neurointervention $345

Thursday Only

AIM Thursday Only $345

Payment Method

Discount Code (If applicable)
Secure Online Credit Card Select this option to pay securely online now
Check Please note that checks must be received by 10/31/2011 and a copy of the registration form should accompany the check.
Please make checks payable to the Cleveland Clinic Educational Foundation and mail to:
The Cleveland Clinic Educational Foundation
Attn: 020804
P.O. Box 931653
Cleveland, OH 44193-1082
Wire/Bank Transfer Wire transfers will incur an additional $30 to the registration fee. Please note that wires must be received by 10/31/2011 and that the name of the registrant/registrants MUST appear on the wire transfer. Please send e-mail to registrar@AIMsymposium.org for bank instructions
Complimentary Select this option if your registration is complimentary
Offline Credit Card Credit Card will be processed manually at a later time

I have read and accept that there is a $95 cancellation fee if canceled in writing by October 21, 2011. No refunds will be made thereafter.