www.suntrac.com
SUNTRAC Services, Inc.

Radiological Training Registration Form

To register, complete information and Fax or Mail to:

Suntrac Services, Inc.
1818 East Main Street
League City, Tx 77573
(281) 338-2133
Fax # (281) 338-2136

---------------------------------Registration Form-------------------------------

Attendee             S.S.N.              Course #              DATE

1.____________      ___-___-___     ____________.___    ___/___/___

2.____________     ___-___-___      ____________.___    ___/___/___

3.____________     ___-___-___      ____________.___    ___/___/___

4.____________     ___-___-___      ____________.___    ___/___/___

5.____________     ___-___-___      ____________.___    ___/___/___

Company Name: _____________________________
Address: ___________________________________ 
              ____________________________________
City:_______________ State:______ Zip:___________

Phone#: ____________________________Fax#: ______________________________
E-mail:  ___________________________________________________

If a registrant is unable to attend a course, a substitute may attend in the place of the original registrant. However, if a registrant is unable to attend and no substitute is made, a course cancellation must be made 14 days prior to scheduled course date. Cancellations made less than 14 days prior to course date are subject to be charged a $100.00 cancellation fee per registrant. Course fees are non-refundable for registrants failing to cancel prior to the start of the course.

Payments Due 14 Days Prior to Class Date

Check#_______ Total Amount Paid $________
Credit Card #_________________________  Exp Date: ________
Credit Card Verification Code:  __________
P.O.#____________________________________

Please send in this registration form to participate in the training class.  You will receive a confirmation
by either e-mail or phone.  If you do not hear from us within 3 days, please give our office a call.

SUNTRAC Services, Inc., 1818 East Main Street, League City, TX. 77573 (281) 338-2133