Send payment and registration form toTraining and Education Office, MBC #03King Faisal Specialist Hospital & Research CentrePO Box 3354Riyadh 11211, Kingdom of Saudi Arabia

Tel: +966 (1) 464-7272 ext. 32600 / 32971Fax: +966 (1) 442-4661email: rctec@kfshrc.edu.sa

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Innovative Approaches in Radiotherapy: Beyond Tomorrow9 - 12 March 2009 / 12 - 15 Rabia Al-Awal 1430 REGISTRATION FORMNOTE: Please print clearly in block capitals and return this form with payment. Also ensure that you use the correct spelling of your name as you wish it to be printed on the certificate.

First Name: Last/Family Name:

Title: Dr. Prof. Mr. Mrs. Miss Other: Gender: Male Female

Profession: Medical Physicist Oncologist Neurosurgeon Radiation Therapist

Biomedical/Clinical Engineer

Vendor Representative

Institution Name:

Business Address:

Tel. No: Fax No: Mobile No:

Email Address:

NOTE: For applicants from outside of Saudi Arabia, please complete the enclosed VISA BIO DATA INFORMATION form.

Fees

Early Registration Fees (by 28 February 2009, student 50% discount):

Late/Onsite Registration Fees (after 28 February 2009, student 50% discount):

SR 350 (for all professionals)

SR 120 (for one day attendance)

SR 450 (for all professionals)

SR 120 (for one day attendance)

Professor Clinical Scientist

Student

Important information 1) Workshop participation is limited; 2) Early registration participants are given workshop attendance priority; 3) Payment is accepted in cash or certified check made payable to: KFSH&RC Research Centre Grant Fund; and 4) Cancellation/Refund Policy: Request for refund must be received one month prior to conference start . Administrative fee of SR 50 will be deducted from all refunds. 5) Please complete the appropriate fields, print form using the 'Print Form' button below and fax back to us. NOTE: This form CANNOT be sent as an e-mail attachment

Workshop Registration & Fee (please select ONLY one workshop):

IMRT/IGRT (Tomotherapy)

IMRT/IGRT (Rapid Arc)

SRS (CyberKnife)

Monte Carlo Simulation

Total fee submitted: SR

Middle Name:

Medical Dosimetrist Other:

Physics Quality Assurance

SR 200 (workshop)

High/Low Dose-Rate Brachytherapy

Oncology Nurse

The Radiation Oncology Process