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The R.O.C.K. Society

Note: All fields are required.

REGISTRANT INFORMATION
Registration Type Guest Physician ($50.00)
Medical Student/Resident/Fellow ($25.00)
Name
Institution
Address
City
State
Zip
Country:
Phone:
Email:

BILLING INFORMATION Same as Purchaser
Name on Card:
Billing Address:
City:
State:
Zip:
Country:

PAYMENT
Total:
Credit Card Type:
Visa MasterCard Amex Discover
Credit Card Number:
Expiration Date:
Card Security Code:
 
Cancellation/Refund Policy
All requests for cancellations must be received in writing. If a written request of cancellation is received at the Administrative Office on or before May 3, 2021, the registration fee, less a $15.00 administrative fee, will be refunded after the meeting. Refund requests received after May 3, 2021 will not be honored.