CIMAGE2018

Registration Form

CIMAGE 2018 Registration Form

The following registration form is for those wishing to attend GE CIMAGE 2018. Each individual attendee must fill out a separate registration form. Field’s with (*) are required to be filled:

Name* *This question is required.

Last Name* *This question is required.

Hospital/Organization* *This question is required.

Job Title *This question is required.

Email Address* *This question is required. This question requires a valid email address.

City* *This question is required.

Province/State* *This question is required.

Postal Code* *This question is required.

Phone Number

Our generous sponsors for the event may wish to contact our attendees via email. Please indicate whether you would like to be included*: *This question is required.

Yes, please include me
No, Thank You

Is this your first CIMAGE conference?* *This question is required.

Please list any dietary restrictions below:

During the event, photographs and/or filming may be taken by the organizers. Do you agree that any such photographs or video that you appear in may be used by GE for promotional use?* *This question is required.

We value our relationship with you and would like to continue to send you information electronically relating to GE. Check box below to provide your consent. You may unsubscribe at any time using this link. *This question is required.