REGISTRATION FORM
Nuclear Medicine Registry Review
Thursday, April 23
th
& Friday, April 24
th
Name:
________________________________________
Address:
________________________________________
City/State/Zip:
________________________________________
Contact Number:
________________________________________
Email:
________________________________________
College Affiliation: ________________________________________
Please return this form with your check in the amount of $50.00 made
payable to CCC&TI by March 31st. Please write Nuclear Medicine
Review in the memo line of your check and mail to:
Caldwell Community College & Technical Institute
Attention: Leslie Deal
2855 Hickory Blvd
Hudson, NC 28638
*Registration form should be postmarked by March 31.
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