AIRP 2016 Registration Form
Fields marked with * are mandatory.
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Family Name *
First Name *
SPRMN Membership number
Participant
Address *
City *
Zip Code *
Country *
Hospital *
Department *
Cell Phone
Fax
Email *
Participant - After April 3
SPRMN Full Member - After April 3
SERAM, SPR, CBR Full Member
SPRMN Member in-training - After April 3
SPRMN Non-Members - After April 3
Radiographer - After April 3
Payment
Payment Type *
Required
Bank Transfer Confirmation
Submit
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